emotional development of child
TRANSCRIPT
Emotional Development
Dr Akash Ardeshana
3rd MDS
Dept of Paedodontics and
Preventive Dentistry
1
Contents
bull Introduction
bull Definition
bull Important of Emotional Development
bull Physiology of emotion
bull Characteristics of commonly seen emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
bull Summary
bull Bibliography
2
Introduction
bull Each of us is born into society with rules expectations
attitudes and values
bull Our task throughout development is to come to understand
ourselves how we feel and function and what our society
deems desirable and appropriate
bull The process of socialization- learning socially acceptable
behavior attitude and values is greatly influence by parents and
other care providers as well as more peripheral people in
childrenrsquos lives
3
bull The emotional development of children and adolescent
represent a huge variation according to age maturity
intellectual development temperament experience family
background cultural background etc
bull These factors play an important role in influencing the childrsquos
development and underlying emotions
4
bull Concurrently these aspects influence the childrsquos ability to cop
with dental treatment
bull According to their age and emotional development some
children remain calm during the treatment while others are
vulnerable and may need more attention and time in order to
make them cooperate for dental treatment
5
Definition
bull Emotion An effective state of consciousness in which
joy sorrow fear hatred or the likes are expressed
bull Emotion a strong feeling state arising subjectively and
directed toward a specific object with physiological
somatic and behavior components
(Dorlandrsquos medical dictionary for health consumers)
6
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Contents
bull Introduction
bull Definition
bull Important of Emotional Development
bull Physiology of emotion
bull Characteristics of commonly seen emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
bull Summary
bull Bibliography
2
Introduction
bull Each of us is born into society with rules expectations
attitudes and values
bull Our task throughout development is to come to understand
ourselves how we feel and function and what our society
deems desirable and appropriate
bull The process of socialization- learning socially acceptable
behavior attitude and values is greatly influence by parents and
other care providers as well as more peripheral people in
childrenrsquos lives
3
bull The emotional development of children and adolescent
represent a huge variation according to age maturity
intellectual development temperament experience family
background cultural background etc
bull These factors play an important role in influencing the childrsquos
development and underlying emotions
4
bull Concurrently these aspects influence the childrsquos ability to cop
with dental treatment
bull According to their age and emotional development some
children remain calm during the treatment while others are
vulnerable and may need more attention and time in order to
make them cooperate for dental treatment
5
Definition
bull Emotion An effective state of consciousness in which
joy sorrow fear hatred or the likes are expressed
bull Emotion a strong feeling state arising subjectively and
directed toward a specific object with physiological
somatic and behavior components
(Dorlandrsquos medical dictionary for health consumers)
6
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Introduction
bull Each of us is born into society with rules expectations
attitudes and values
bull Our task throughout development is to come to understand
ourselves how we feel and function and what our society
deems desirable and appropriate
bull The process of socialization- learning socially acceptable
behavior attitude and values is greatly influence by parents and
other care providers as well as more peripheral people in
childrenrsquos lives
3
bull The emotional development of children and adolescent
represent a huge variation according to age maturity
intellectual development temperament experience family
background cultural background etc
bull These factors play an important role in influencing the childrsquos
development and underlying emotions
4
bull Concurrently these aspects influence the childrsquos ability to cop
with dental treatment
bull According to their age and emotional development some
children remain calm during the treatment while others are
vulnerable and may need more attention and time in order to
make them cooperate for dental treatment
5
Definition
bull Emotion An effective state of consciousness in which
joy sorrow fear hatred or the likes are expressed
bull Emotion a strong feeling state arising subjectively and
directed toward a specific object with physiological
somatic and behavior components
(Dorlandrsquos medical dictionary for health consumers)
6
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull The emotional development of children and adolescent
represent a huge variation according to age maturity
intellectual development temperament experience family
background cultural background etc
bull These factors play an important role in influencing the childrsquos
development and underlying emotions
4
bull Concurrently these aspects influence the childrsquos ability to cop
with dental treatment
bull According to their age and emotional development some
children remain calm during the treatment while others are
vulnerable and may need more attention and time in order to
make them cooperate for dental treatment
5
Definition
bull Emotion An effective state of consciousness in which
joy sorrow fear hatred or the likes are expressed
bull Emotion a strong feeling state arising subjectively and
directed toward a specific object with physiological
somatic and behavior components
(Dorlandrsquos medical dictionary for health consumers)
6
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Concurrently these aspects influence the childrsquos ability to cop
with dental treatment
bull According to their age and emotional development some
children remain calm during the treatment while others are
vulnerable and may need more attention and time in order to
make them cooperate for dental treatment
5
Definition
bull Emotion An effective state of consciousness in which
joy sorrow fear hatred or the likes are expressed
bull Emotion a strong feeling state arising subjectively and
directed toward a specific object with physiological
somatic and behavior components
(Dorlandrsquos medical dictionary for health consumers)
6
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Definition
bull Emotion An effective state of consciousness in which
joy sorrow fear hatred or the likes are expressed
bull Emotion a strong feeling state arising subjectively and
directed toward a specific object with physiological
somatic and behavior components
(Dorlandrsquos medical dictionary for health consumers)
6
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull (Co T Morgan R A King and N M Robinson 1979)
bull There is no concise definition because an emotion is many
things at oncethe way we feel when we are emotionalthe
behavioral arousal the physiological or bodily basisthat
emotions are expressed by language facial expressions and
gesturesthatsome emotionsare very much like motive
states in that they drive behavior
7
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Emotion is a complex set of interactions among subjective and
objective factors mediated by neuralhormonal systems which
can (a) give rise to affective experiences such as feelings of
arousal pleasuredispleasure (b) generate cognitive
processes such as emotionally relevant perceptual effects
appraisals labeling processes (c) activate widespread
physiological adjustments to the arousing conditions and (d)
lead to behavior that is often but not always expressive goal
directed and adaptive
-Kleinginna and Kleinginna (1981)
8
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
POSITIVE EMOTION
Affection amusement joy
curiosity and happiness
Essential to normal
development
NEGATIVE EMOTION
Fear anger jealousy
Harmful to development
Emotional security = Happy child 9
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Better understanding of the child
bull To understand the problem of psychological
origin
bull Deliver dental treatment service in a meaningful
manner
bull Establish effective communication
bull Better teaching of primary and preventive care
bull Effective treatment planning and execution
bull Provide a comfortable environment
Importance of emotional development
10
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear
Same
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Worry
Self pit
Guilty feeling
Depression
Irritability
boredom
Delight Elation
Hopeful anticipation
Affection
Sex
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
11
Different emotions at different stages of life
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Physiology of emotion
bull Development of emotion depends on maturation in the nervous
system and the endocrine system
bull Differences in emotional responsiveness between children and
adults appear to be partly due to cortical immaturity and partly
due to deference in endocrine out put
12
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
13
Nervous system
CNS PNS
SOMATIC AUTONOMIC
SYMPATHETIC
PERASYMPATHETIC
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
14
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull The sympathetic system is active during aroused states and prepares the
body for extensive action by increasing the hart rate blood pressure blood
glucose level and raising the level of certain hormones in the blood
bull Nerve impulses in this system which reach the inner part of the adrenal
glands located on the top of the kidneys trigger the secretion of
epinephrine and nor epinephrine
bull This part of the ANS that is active in may strong emotion especially fear
and anger
bull Parasympathetic systems tends to be active when we are calm and relaxed
15
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull At the birth cortex development is completed frontal lobe is immature and
has little influence on the functions of the lower part of he brain resulting in
imbalanced emotion
bull Hence emotional response of the child is quickly aroused but short liven
16
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull In 2-5 years and 11 -12 years adrenal gland gain weight rapidly and
liberation of adrenaline in blood is vigorous as a result of which a
preschooler is highly emotional and emotional outburst are prolonged too
give rise to physiological sign of emotional disturbance
17
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Activity of brain in certain regions including hypothalamus and other part
of nervous system directly influence muscles and internal organs to initiate
body changes
bull Indirect stimulating adrenal hormones to other body changes and preparing
the body for light or flight
18
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Characteristics of commonly seen
emotion in a child
bull Distress or Cry
bull Anger
bull Fear
bull Anxiety
bull Phobia
19
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Distress or Cry
bull The most common way a child expresses fear is by crying at
the dentistrsquos office
bull Crying like other emotional manifestations of human
behaviour is an expression of personality of an individual
bull Crying is liable to be the result of conflict with the developing
ego and with his newly found interests
bull After the age of one and a half child develops a variety of
fears and cries for the security of his motherrsquos company
20
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
At birth bull Primary emotion
bull With vigorous body expression
bull Usually due to hungr colic on any internal cause
bull At six monthsbull Greatly replaced by a milder expression of fussing or vocalization
bull During preschoolbull Only for the reason of physical pain as he is disappointed by his
environment
21
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull During school year
bull pressure helps him to outgrow the crying habit which decrease rapidly
bull After this till 15 years crying occurs very seldom
bull In young adult
bull ultimately it becomes a limited quiet crying in private only for reason of
grief or other intense emotion
22
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Different type of cry seen In children
Following four type of crying are usually seen in children (Elsbach 1963)
1 Obstinate cry
2 Frightened cry
3 Hurt cry
4 Compensatory cry
23
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Obstinate cry
bull The child throw a temper tantrum to through dental treatment
bull It is loud high pitched
bull pause and repeated over and over again
bull Characterized as a siren like wail
bull represents the childrsquos external response to anxiety
24
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Frightened cry
bull Usually accompanied by a torrent of tears
bull Convulsive breath-catching sobs
bull Usually the child emitting this type of cry has been
overwhelmed by the situation
25
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Hurt cry
bull May be loud and more frequent
bull Frequently accompanied by a small whimper
bull Initially a child in discomfort shows a single tear filling the
corner of the eye and running down the childrsquos cheek with out
making any sound or resistance to the treatment procedure
26
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Compensatory cry
bull It is not a cry at all
bull It is a sound that child makes to drown out the noise for
example a drill
bull Usually the cry sound is slow monotone
bull It is a sort of coping mechanism to unpleasant auditory stimuli
finding himself uncomfortable in the situation
27
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Title Correlation of crying pattern to clinical diagnosis of children
undergoing treatment
Author Chunawalla YK Bohari MR Bijle MN
Journal International Journal of Contemporary Dentistry 2010 Jan 111(1)
Level of
evidence
IIIb
aim To correlate the Crying pattern to Clinical Diagnosis of children undergoing
treatment
Method Children in the age group 4-9 years were divided into Group1 (40 children)
amp Group 2 (60 children) and their cries were recorded using a video
camera Different cries analyzed were frightened pain obstinate
manipulative and boredom cry on the basis of their description in the
literature Group I was subjected to detailed clinical examination and Group
II to various dental procedures
Result The most commonly observed cry was pain cry Pain cry was mostly
associated with dento-alveolar abscess With respect to dental procedures
pain cry was commonly associated with use of inject able aids frightened
cry and compensatory cry with the use of dental drill
Conclusion Cries could be means of communication and asset in clinical diagnosis
28
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Anger
bull Outburst of the emotion is caused by the childrsquos lack of skill in
handling the situation
bull Infant and young children responnd in anger in a direct and
primitive manner but as they develop the responses become
violent and more symbolic
29
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull 15 months children express anger by throwing objects
bull Two-year olds attack other childen with an intention to hurt
bull Four year olds express their anger through begging
bull Five year olds have less expression of anger
bull Six year olds have a renewal of violent method of expression
of anger
30
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Seven year ones display less aggressiveness through kicking
througwing objects is observed
bull 8-9 years olds anger is expressed through feelings It become
directed towards a single person
bull 10 year oldrsquos anger may become violent and may be expressed
physically
bull 12 years olds express anger verbally
bull 14 years olds may take out his anger on someone else 31
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Fearhellip
bull The unpleasant emotioonal state consisting of psychological
and psycho-physiological responses to a real external threat or
danger including agitation alertness tension and mobilization
of the alarmed reaction (Dorland Medical Dictonary)
bull It is defined as a painful feeling of imending danger evil
trouble etc ( Delbridge )
bull Defined as a reaction to a known danger (Rubin)
32
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Fear related emotional pattern
bull Shynesshellip
bull Characterized by shrinking from contact with who are stranger
and unfamiliar
bull It is always stimulated by people never by objects animals or
situations
33
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull In baby usual response in
shyness is crying turning the
head
bull If able to walk- run away and
hide
bull Older children- by blushing
by stuttering by nervous
mannerisms- a pulling at the
ears or clothing shifting from
one foot to the other and
bending the head to one side 34
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Embarrassment
bull Fear reaction to people not to objects or situation
bull Stimulated by uncertainty about how people will judge one and onersquos
behavior
bull State of self conscious distress
bull Not present in a child less than 5 or 6 years old
35
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Anxietyhellip
bull It is an uneasy mental state concerning impending or anticipated ill
bull Like worry anxiety is due to imaginary rather than real cause
bull Worry is related to specific situation whereas anxiety is a generalized
emotional state
bull Worry come from an objective problem whereas antiety comes from a
subjective proble
36
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
0-2 2-4 4-7 8-10 11-13
bullStranger
bullLoud noises
bullLoss of
support
bullStrange
objects
bullBeing alone
bullDarkness
bullanimals
bullEnvironment
al threat
bullimaginary
creatures
bullanimals
-
-Animal
-Burglar
-Personal
harmharm
others
-Animals
-Separation
from parents
37
Different types of fears corresponding to age
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Type of Fear
38
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Innate fear
bull without stimuli or previous experience)
bull It is thus also dependent on the vulnerability of the individual
39
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Objective Fear
bull Produced by direct physical stimulation of the sense organs
and are generally not of parental origin
bull Objective fears are responses to stimuli that are felt seen
heard smelled or tasted and are of a disagreeable or
unpleasant nature
40
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Subjective fear
bull Fear based on somebody elsersquos
experience without actually
undergoing dental treatment himself
bull The majority of the children who visit
the dentist are anxious in particular
during first visit
bull Their anxiety level may be heightened
by stories from friends relatives
parents who have threatened them
using dentistrsquos visit as punishment for
bad behavior 41
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Suggestive fear acquired by imitation by observation of
other
bull Imitative fears transmitted while displayed by other (parent)
and acquired by the child without being aware of it Displayed
emotion in parentrsquos face creates more impression than verbal
suggestions
bull Even a tight clenching of the childrsquos hand in dental office
while undergoing dental treatment creates fear in childrsquos mind
about dental treatment
bull Imaginative fear as the childrsquos imaginative capability
develop they become more intense with age and mental
development with certain age42
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
43
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Value of fear
bull Fear lowers the threshold of pain so that every pain produced
during the dental treatment becomes magnified
bull Fear has safety value when given proper direction and control
bull Since fear producing stimuli can cause actual harm to the
child fear is protective mechanism for self protection
44
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull The nature of fear can be utilizes to keep the child away from
dangerous situation of either social or physical nature
bull If child does not fear punishment or parental disfavor his
behavior may make him a threat to society
45
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull The child should be taught that dental office is not a place to
fear
bull Dentistry should not be employed as a threat or punishment
bull using it in this manner creates fear of dentistry or dentist
bull On the other hand if the child has become attached to the
dentist fear of loss of his approval may have some value in
motivating the child for dental treatment
46
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Fear evoking dental situation
bull Anesthetic administration locally by injection
bull Extraction
bull sound of drill
47
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Title Childs dental fear cause related factors and the influence of audiovisual
modeling
Author Mungara J1 Injeti M Joseph E Elangovan A Sakthivel R Selvaraju G
Journal J Indian Soc Pedod Prev Dent 2013 Oct-Dec31(4)215-20
Level of
evidence
IIIa
aim To assess the degree of fear provoked by various stimuli in the dental office and to
evaluate the effect of audiovisual modeling on dental fear of children using CFSS-DS
Method Ninety children were divided equally into experimental (group I) and control (group II)
groups and were assessed in two visits for their degree of fear and the effect of
audiovisual modeling with the help of CFSS-DS
Result The most fear-provoking stimulus for children was injection and the least was to open
the mouth and having somebody look at them There was no statistically significant
difference in the overall mean CFSS-DS scores between the two groups during the
initial session (P gt 005) However in the final session a statistically significant
difference was observed in the overall mean fear scores between the groups (P lt
001) Significant improvement was seen in group I while no significant change was
noted in case of group II
Conclusion Audiovisual modeling resulted in a significant reduction of overall fear as well as
specific fear in relation to most of the items A significant reduction of fear toward
dentists doctors in general injections being looked at the sight sounds and act of
the dentist drilling and having the nurse clean their teeth was observed48
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Factors causing dental fear
49
1 Fear of pain or its anticipation
2 Fear of betrayal or A lack of trust
3 Fear of loss of control
4 Fear of the unknown
5 Fear of intrusion
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Fear of pain or its anticipation
bull The link between actual or misinterpreted pain or the anticipation of pain
and dental fear is well established
bull We frequently see children who report that they sais that they were
experiencing pain but the dentist ignored them and carried on
bull So it is very important as dentist to recognize and address the pain
symptoms of the children
50
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Fear of betrayal
bull Trust may also be learned either direct from the behavior of the parents or
peers
bull It is therefore theoretically possible that children learn to trust or distrust
dental personnel from their parents before they have any direct contact with
such person
51
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Fear of loss of control
52
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Fear of unknown
bull In anyonersquos eyes a visit to the dentist may be classified as a potentially
threatening condition
bull Helpful comment from the mother such as it will not hurt even before an
examination are going to raise the possibility in the childrsquos mind of being
hurt
53
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Fear of intrusion
bull Intrusion involves impinging on the patientrsquos personal
space and into a bodily cavity the mouth
bull Impinging the patientrsquos personal space is something
that is taken for granted by professionals
54
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Features of fear
bull Fear is a package of reaction that tend to occur together simultaneously or
sequentially About 70 acquire dental fear at an early age This emotion
may present the following main two expression
1 Tendency to freeze which reaches its extreme in the for of death
2 Startle scream run away from the scene of danger ie flight
ndash It turns a shift from freeze reaction to flight
55
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Syptoms of intense fear
bull Unpleasant feeling of
terror
bull Pounding of the heart
bull Tense muscle
bull Liability to startle
bull Dryness of throught and
mouth
bull Sinking feeling
bull Nausia feeling
bull Urge to urinate
bull Irritability
bull Anger
bull Weakness
bull Sense of unreality
56
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Chronic fear leads tohellip
bull Tiredness
bull Difficulty in sleeing and bad dream
bull Restlessness
bull Loss of apatite
bull Aggression
bull Avoidance of tension producing situation
57
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Physiological sign of fear
bull Pale sweaty skin
bull Hair standing on end
bull Dilatation of pupils
bull Rapid breathing
bull Increased heart-rate
58
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Response to fear
bull Described at three level
1 Intellectual level where the child is really to accept the
situation and face the difficulties to achieved result and
benefits ( usually seen at adolescent age)
2 Emotional level usually the child shows the fight or flight
response which acts as an instantaneous response (seen in
school age)
3 Hedonic level usually reflected as self-centeredness thereby
accepting what is comfortable and rejecting what is not
without too much concern for the outcome or nature of the
treatment59
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Measuring child dental fear
bull Measuring child dental fear involves several
difficulties regarding technique as well as
interpretations of results Four main types of
measures have been used
bull 1 rating of child behavior during dental visits
bull 2 psychometric scales
bull 3 physiological measures
bull 4 projective techniques
60
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Commonly use fear scale
Adult and children Child specific
Kleinknechtrsquos
Dental Fear
Survey17
Venham Picture Scale
Gatchelrsquos
10-Point Fear
Scale22
Childrenrsquos Fear
Survey Schedule
Fear of dental pain
questionnaire
Morinrsquos adolescentrsquos fear
of dental treatment
cognitive inventory
61
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Childrenrsquos Fear
Survey Schedule
bull The Childrenrsquos Fear Survey Schedule or CFSS is designed to
assess a range of general fears in children
bull Given by Scherer and Nakamura (1968)
bull It consists of 80 items on a 5-points likert scle
bull A dental subscale (CFSS-DS) has been developed by Cuthbert
and Melamed that consists of 15 items rated on a five-point
scale ranging from 1 (not afraid) to 5 (very afraid)
62
Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Scale scores are calculated by summing item scores the total
score can range from 15 to 75
bull Scores above 38 indicate significant dental fear
bull The CFSS-DS has been found to discriminate between
children who do and do not display dental fear and behavioral
problems during dental treatment
63Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their
quality and application The Journal of the American Dental Association 2000
Oct 31131(10)1449-57
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
64
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull The cognitive physiological behavioral ad emotional aspect
of dental fear are not measured which under mines any clime
that the CFSS-DS is theoretically sound measure of dental
treatment
65
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Venham Picture Scale
bull Age group 4-11 years
bull This scale consists of a series of eight paired drawings of a
child
bull Each pair consists of a child in a non fearful pose and a fearful
pose (for example running away)
bull The respondent is asked to indicate for each pair which
picture more accurately reflects his or her feelings at the time
bull Scores are determined by summing the number of instances in
which the child selects the high-fear stimulus
66
Venham LL Gaulin-Kremer E A self-report measure of situational
anxiety for young children Pediatr Dent 1979 Jun1(2)91-6
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Venham LL Gaulin-Kremer E A
self-report measure of situational
anxiety for young children Pediatr
67
The children were asked to point at the
figure they felt most like at that moment
All cards were shown in their numbered
order
If the child pointed at the lsquoanxiousrsquo figure a
score of one was recorded if the child
pointed at the lsquononanxiousrsquo figure a score
of zero was recorded
The number of times the lsquoanxiousrsquo figure
was chosen was totalled to give a final
score (minimum score zero maximum
score eight)
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Kleinknechtrsquos Dental Fear
Survey
bull Age group above 12 year
bull Second most commonly use
bull Originally developed as 27 item scale (Kleinknechtrsquo et al 1978) and
subsequently reduced to 20 items
bull Kleinknechtrsquos Dental Fear Survey asks respondents to rate their anxieties
about 27 specific situationsmdashsuch as making an appointment or hearing the
dental drillmdashon a five-point Likert scale ranging from ldquononerdquo to ldquogreatrdquo
bull Three dimensions of the questionnaire have been derived from factor
analysis avoidance of dental treatment somatic symptoms of anxiety and
anxiety caused by dental stimuli
bull These factors are reliable and stable across different groups of respondents
68Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to their quality
and application The Journal of the American Dental Association 2000 Oct
31131(10)1449-57
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
69Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor
analysis of the dental fear survey with cross-validation Journal of the
American Dental Association (1939) 1984 Jan108(1)59
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
70
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
71
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Short Dental Fear Question (SDFQ
bull S Jaakkola et al 2009
bull Use for adul
bull Above 15 years
72Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg T
Mattila ML Sillanpaumlauml M Dental fear one single clinical question for measurement
Open Dent J 2009 Jul 283(1)161-216
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Option 4 a b c describes situations in which there are many great
difficulties
bull option 3 ldquoI was nervous the treatment could only just be carried outrdquo
means that the patientrsquos treatment takes more time than normally
bull option 2 ldquoI was nervous but nevertheless the treatment was carried out
successfullyrdquo means that the patient is a little nervous but perhaps nobody
else is able to notice it
bull option 1rdquoI was totally relaxed during the treatmentrdquo is the answer of the
patient who is relaxed and confident during the treatment
73
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Gatchelrsquos 10-Point Fear
Scale
bull For adult
bull This is a single-item scale that asks respondents to rate their
dental fear on a 10- point scale
bull A score of 1 indicates no dental fear 5 moderate fear and 10
extreme fear
bull A score of 8 or greater is considered to indicate a significant
degree of anxiety
74Gatchel RJ Ingersoll BD Bowman L Robertson MC Walker C The prevalence of
dental fear and avoidance a recent survey study Journal of the American Dental
Association (1939) 1983 Oct107(4)609-10
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory
bull In 1991 Gauthier et al published the Adolescentsrsquo Fear of Dental
Treatment Cognitive Inventory (AFDTCI) developed by Morin in 1987
bull The AFDTCI evaluates thoughts and ideas that an adolescent may
experience during dental treatment
bull The questionnaire originally consisted of 42 questions with ordinal 1- to 5-
point scales but after assessment by 8 experts it was reduced to 29 items
75
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull A test using adolescent subjects (n = 343) led to the removal of 6 more
items leaving 23 items in all The scores on the AFDTCI may range from
23 (no fear) to 115 (high fear)
bull This scale measures the thoughts and ideas an adolescent may have during
dental treatment
bull It is unique among the childrenrsquos scales in that it focuses solely on the
cognitive manifestations of fear
76
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Fear of Dental Pain questionnaire
bull Fear of dental pain was measured using the FDPQ
bull The original questionnaire consists of 18 items and assesses fear
bull of pain associated with a variety of dental procedures
bull Each item is answered on a rating of 1 (no fear) to 5 (extreme fear)
resulting in a possible total score of 18ndash90
bull The FDPQ
bull was developed as a dental equivalent of the Fear of Pain Questionnaire-III
77Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English version of
the Fear of Dental Pain questionnaire European journal of oral sciences 2006 Jun
1114(3)204-8
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
78
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Tiwari N Tiwari S Thakur R Agrawal N Shashikiran ND Singla S Evaluation
of treatment related fear using a newly developed fear scale for childrenldquoFear
assessment picture scalerdquo and its association with physiological response
Contemporary clinical dentistry 2015 Jul6(3)327 79
6-8 years age
The FAPS was designed by
taking a part of Klingbergrsquos
children dental fear picture
test (CDFP) pointing picture
what do you feel when a
dentist checks your oral
cavity with instruments
Fear assessment picture
scale
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Behavioral treatment of fearful
childrenbull Communication
bull Euphemisms
bull The guidance cooperation model
bull Time-structuring
bull Distraction
bull Guided imagery
bull Behavior modification
bull Parent in operatory
bull
80
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Anxiety
bull The term anxiety entered the field of psychology as a
translation of the German word ldquoAngstrdquo which was used by
Freud in 1936
bull Anxiety is a normal part of childhood and every child goes
through phases A phase is temporary and usually harmless
bull But children who suffer from an anxiety disorder experience
fear nervousness and shyness and they start to avoid places
and activities
81
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Anxiety
bull Is an emotion similar to fear but arising without any objective
source of danger
bull Is a reaction to unknown danger
bull It is a learned process being in response to onersquos environment
bull As an anxiety depends on the ability to imagine it develops
later than fear
82
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Definition
bull It is often defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from
within rather than from without
bull Anxiety a state of uneasiness or tension caused by
apprehension of possible future missfortune dange etc
(collins english dictonary)
bull Anxiety is an emotion characterized by an unpleasant state of
inner turmoil often accompanied by nervous behavior such as
pacing back and forth somatic complaints and rumination
83
(Seligman MEP Walker EF Rosenhan DL Abnormal psychology (4th ed)
New York WW Norton amp Company)
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Types of anxiety
Trait anxiety
bull It is life-long pattern of anxiety as a temperament feature
bull It is a preset level of anxiety experienced by an individual who
has tendency to be more anxious to react less appropriately to
anxiety provoking stimuli
bull These children are generally jittery skittish and
hypersensitive to stimuli
84
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
State anxietybull These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation
bull It is a fear nervousness discomfort and the arousal of the autonomic
nervous system induced temporarily by situations perceived as dangerous
bull Examples A child feels anxious when confronted by a large strange
animal A person feels anxious to get on an airplane for the first time
85
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Free floating anxiety
bull It is condition of persistently anxious mood in which the cause
of emotion is unknown and many other thoughts or event
trigger the anxiety
Situational anxiety
bull It is only seen in specific situations or objects
General anxiety
bull where the individual experiences a chronic pervasive feeling
of anxiousness whatever may be the external circumstances
86
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Subtypes of anxietyAssociated
bull This is process of classic conditioning where by previously
neutral stimuli become the cause for arousal and anxiety by
pairing them with pain or the negative experiences of others
Appraisal
bull Here anxiety is concerned with cognition or the way we think
bull It involved reconstruction of negative experiences rather than
positive happenings that account for the arousal of anxiety
87
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Cause of anxiety
Uncertainty
bull Fear of unknown is anxiety provoking
bull In dental clinic new patientrsquos anxiety can be due to uncertainty
they feel about what await them after initial first appointment
check up
88
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Previous learning
bull In such case anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning
involved in dental anxiety may have been more indirect
depending upon the experience of other people
bull Maternal anxiety play an important role in the childrsquos anxiety
level determinant
bull A mother with higher anxiety will have a child usually
showing a negative behavior as a result of hisher high level of
anxiety
89
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Title Maternal Dental Anxiety and its Effect on Caries Experience Among Children in
Udaipur India
Author Shabnam Gulzar Khawja1 Ruchi Arora2 Altaf Hussain Shah3 Amjad Hassan Wyne4
and Anshu Sharma
Journal J Clin Diagn Res 2015 Jun 9(6)
Level of
evidence
IIA
Aim To evaluate dental anxiety among mothers and its possible relationship with caries
experience in their children in Udaipur city India
Method A cross-sectional survey was designed A total of 187 mother-child pairs were
recruited for the study The childrenrsquos age ranged from 3-14 years Modified Dental
Anxiety Scale (MDAS) The World Health Organization (WHO) criteria was utilized for
the diagnosis of dental caries in children DMFT (Decayed missing and filled teeth)
and DMFS (Decayed missing and filled surfaces) scores were then calculated
Result Almost half (497) of the mothers reported as being lsquofairly anxiousrsquo or lsquovery anxiousrsquo
There was a significant (p=001) difference in maternal dental anxiety level in relation
to age of the children Mothers of younger children reported higher anxiety scores
Similarly mothers with lesser education and lesser family income reported higher
anxiety scores The mean decayed score in children of very anxious mothers and
phobic mothers was significantly (p=001) higher as compared to the children of the
mothers with lower anxiety levels
Conclusion There was a strong positive association between maternal dental anxiety and
childrenrsquos dental caries experience
90
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Biological difference
bull Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism
91
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Dental anxiety and its implications for
paediatric dentists
bull With regard to paediatric dentistry it is important to keep in
mind that anxious patients manifest their anxiety in different
ways Some can respond with disruptive or interruptive
behavior
bull Others can respond by sweating and an increased heart rate
whereas other patients do not show any external sign of
anxiety
92
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Dental anxiety and the avoidance of situations that involve
dental treatment and care have frequently been considered to
be the source of serious oral health problems in children and
adults
bull High levels of anxiety prevent a patient from cooperating fully
with their dentist which can result in lost time for the
practitioner and unnecessary difficulties when carrying out the
treatment and most importantly can limit the effectiveness of
the dental treatment and prevent the early detection of
pathological processes
93
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Methods of assessing dental
anxiety
bull Objective
bull subjective
94
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
95
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull All the physiological parameters described can be used to measure anxiety
in a patient but they all require a monitoring team financial expenditure
and extra time in the dental clinic For this reason these types of measure
are not commonly used in dental clinics
[Klingberg et al 1995]
96
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Anxiety rating scale
97
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Corahrsquos Dental
Anxiety Scalebull The most widely used for measurement of dental anxiety
bull Developed by Norman Corah and Panterra (1969)
bull DAS is a four-item measure
bull Respondents are asked about four dentally related situations and are asked
to indicate which of four responses (of increasing severity) is closest to
their likely response to that situation
98
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Corah NL Development of a dental anxiety scale Journal of dental
research 1969 Jul 148(4)596
99
Scoring the Dental Anxiety
Scale Revised (DAS-R)
a = 1 b = 2 c = 3 d = 4 e = 5
Total possible = 20
Anxiety rating
bull 9 - 12 = moderate anxiety but
have specific stressors that
should be discussed and
managed
bull 13 - 14 = high anxiety
bull 15 - 20 = severe anxiety (or
phobia) May be manageable
with the Dental
Concerns Assessment but might
require the help of a mental
health therapist
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull First two question related to general anxiety and the second two questions
seeming to related to anticipated fear of specific situation
bull Advantages of DAS fast it can aid the dentist to be aware of what to
expected from patient and take measurement to help alleviate the anxiety of
the patient
bull Second it can be self administered in the waiting room in 2 minutes
100
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Modified dental anxiety scale
bull Corahrsquos DAS has been modifiedby the addition of a fifth item that asks
about responses to administration of local anesthetic and by a change in the
response format
bull Given y Humphris et al 1995
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
101
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
102
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
103
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
MODIFIED CHILD DENTAL ANXIETY SCALE
How do you feel about
104
How do you feel about relaxed-
not
worried
very
slightly
worried
fairly
worried
worried
a lot
very
worried
going to the dentist generally
having your teeth looked at [examination]
having your teeth scraped and polished [prophylaxis]
having an injection in the gum [local anaesthedc]
having a filling 2
having a tooth taken our [extraction)
being put to sleep to have treatment [general
anaesthesia]
having a mixture of gas and air which will help you to
feel comfortable for treatment but which cannot put you
to sleep [inhalation sedation]
Humphris GM Wong HM Lee GT Preliminary
validation and reliability of the modified child
dental anxiety scale Psychological reports
1998 Dec 183(3 suppl)1179-86
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
105
Faces version of the Modified Child
Dental Anxiety Scale
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Dental anxiety question (DAQ)
bull The Dental Anxiety Question or DAQ is a single-item construct ldquoAre you
afraid of going to the dentistrdquo
bull It has four possible responses ldquonordquo ldquoa littlerdquo ldquoyes quiterdquo ldquoyes veryrdquo
bull These responses are scored from 1 to 4 in the direction of increasing
anxiety
bull For some purposes such as screening people who are likely to be highly
anxious about dental treatment it is a useful and brief tool although it has a
tendency to overestimate the prevalence of severe dental anxiety
106
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Spielbergerrsquos State-Trait Anxiety
Inventorybull Spielberger (1983)
bull State-Trait Anxiety Inventory or STAI distinguishes between anxiety as a
general aspect of personality (trait anxiety) and anxiety as a response to a
specific situation (state anxiety)
bull It consists of 40 statements 20 of which measure trait anxiety and 20 state
anxiety
bull Items are scored on four point scales with response categories varying
according to the nature of the question
bull Although the STAI was not specifically designed for use in dentistry it is
commonly used and has been proven to significant positive correlation with
CDAS
Spielberger CD Manual for the State-Trait Anxiety Inventory STAI
(form Y)( self-evaluation questionnaire)
107
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull The facial scale was developed by McGrath et al (1996)
bull The FAS comprises nine drawings of childrenrsquos faces whose expressions
vary according to the level of discomfort
bull Although this scale has been mainly be used to measure pain intensity in
children in hospitals it was originally designed to measure their affective
discomfort too (associated emotional distress)
bull faces ranges from a smiling face to a frowning one with eyes closed
wailing and mouth turned down (which shows the highest level of
discomfort)
108
Facial Affective Scale (FAS)
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face facial
scales Psicothema 201325(4)446-51
109
No anxiety A little anxiety Some anxiety High anxiety Very highanxiety
No anxiety Some anxiety Very high anxiety
Modified FAS using 5 and 3 faces and their
corresponding descriptors
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Facial image scale
bull The Facial Image Scale comprises a row of five faces ranging from very
happy to very unhappy
bull The children were asked to point at which face they felt most like at that
moment
bull The scale is scored by giving a value of one to the most positive affect face
and five to the most negative affect face
Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52
110
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Venham Anxiety and Behavior
Rating Scalesbull These two scales assess the anxiety and uncooperative behavior of children
in the dental setting
bull Both scales consist of five behaviorally defined categories ranging from 0
to 5 with higher scores indicating greater levels of anxiety or lack of
cooperation
bull This is one of the most reliable indicators of observed anxiety and has been
used predominantly in anxiety assessment protocol
Venham L Gaulin-Kremer E Munster
E Bengston-Audia D Cohan J Interval rating
scales for childrenrsquos dental anxiety and
uncooperative behavior Paediatr Dent 1980
2195-202
111
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
112
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
The Smiley Faces Program
bull The Smiley Faces Program (SFP) is a four item computerised trait dental
anxiety scale using faces as a response set to assess dental anxiety in
children
bull Using multimedia toolbook an interactive computerised version of the
Facial Image Scale was developed this Windows program was entitled
Smiley Faces
Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62 113
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Questions
bull 1having to have dental treatment the following day
bull 2 sitting in the waiting room
bull 3 about to have a tooth drilled and
bull 4 about to have a local anaesthetic injection
bull Question 1 flashes up on the screen for five seconds lsquoIf you had to go to
the dentist tomorrow to get some treatment how would you feelrsquo
bull The question leaves the screen and a face in a picture frame with a neutral
expression is shown
bull The child can click on the happy face for the face in the picture frame to
become happier and the unhappy face to become sadder
bull There is a choice of seven faces
114
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Anxiety thermometer
bull This is the image of thermometer
where the respondent selects a point
on the thermometer to rate anxiety
where 1 no anxiety and 10= extreme
anxiety
115
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Childrenrsquos drawings as a measure
of anxiety level
Puura A Puura K Rorarius M ANNILA P Viitanen H Baer G Childrens drawings as a
measure of anxiety level a clinical pilot study Pediatric Anesthesia 2005 Mar
115(3)190-3
116
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Phobia
bull Is an irrigational fear resulting in the conscious avoidance of a specific
feared object activity or situation
bull It may be defined as a persistent excessive unreasonable fear of a specific
object activity or situation that results in a compelling desire to avoid the
dreaded object
117
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Characteristics of phobia
bull Being out of proportion to the stimulus or situation
bull Cannot be reasoned with
bull Being out of voluntary control
bull Persistent and inadaptable
118
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Shelhan (1982) divided anxiety and phobia into two major
group
bull 1 endogenous
bull 2 exogenous ( non ndashendogenous)
119
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Non-endogenous
bull This is a psychologically affected group which involves
situation related anticipatory anxiety symptoms such as
bull Moist palms
bull Fluttery stomach
bull Fine hand tremor
bull Shaky inside
bull Rapid hart beat
120
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull These are the symptoms seen when normal individuals are
arrested or threatened
bull the main cause is in the external environment
bull It is an anxiety or phobia due to a factor ldquoto be produced from
the outsiderdquo
bull Thus the individual can readily identify the etiological agent
121
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Endogenous
bull This anxiety is present without prior warning or the presence
of ay detectable stress situation
bull The cause is ldquoto be produced from withinrdquo
bull This type of anxiety has a more severe cluster of symptoms
such as
bull Light headedness or dizziness
bull Difficulty in breathing
bull Parasthesia
bull Hyper ventilation
bull Chest pain
bull Losing control122
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Some of the phobias are
bull Acrophobia ndash height
bull Agoraphobia ndash open space
bull Arachnophobia ndash spider
bull Anthrophobia ndash people
bull aquaphobia ndash water
bull Astraphobia ndash lightening
bull Claustrophobia ndash closed space
bull Cynophobia ndash dog
bull Zoophobia ndash Animals
bull Nyclophobia ndash darkness
bull Pyrophobia - fire
bull Xenophobia ndash stranger 123
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Situational phobia
bull Is popularly interpreted as a fear of open space but has wider
implication
bull It usually refers to a cluster of complaints
bull In addition to open or crowded places they also fear public
transport bridges tunnels benign alone at home or being
away from home etc
bull Characteristics
bull Dizziness loss of bladder control or bowel control cardiac
distress
124
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Social phobia
bull It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
bull Main types of social phobia are public speaking fear of eating
fear of blushing
125
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Phobia in childhood
bull The most common phobia in childhood is the fear of animal
bull This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years
bull Another common phobia is of darkness a fear experienced b
children between the age of 4 and 6 years
bull This is most likely due to the imagination of the child as to
various creature lurking out in the dark
126
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull School phobia is an exaggerated fear of attending school and
occurs in all children peaking around 1-12 years
bull A fear of the various activities connected to school such as
new faces and challenges fear of leaving home
bull In 12 years children of both sexes previous aversive dental
experiences are more closely related to dental phobia than
general fear
bull At adolescent period most children outgrow their fear
bull Two phobias commonly seen are fear of blushing and fear of
being looked at
127
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Summary
128
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Referances
bull Tandon S textbook of pedodontics 2nd edition Parash publication 20089
bull Newton JT Buck DJ Anxiety and pain measures in dentistry a guide to
their quality and application The Journal of the American Dental
Association 2000 Oct 31131(10)1449-57
bull Venham LL Gaulin-Kremer E A self-report measure of situational anxiety
for young children Pediatr Dent 1979 Jun1(2)91-6
bull Kleinknecht RA Thorndike RM McGlynn FD Harkavy J Factor analysis
of the dental fear survey with cross-validation Journal of the American
Dental Association (1939) 1984 Jan108(1)59
129
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Jaakkola S Rautava P Alanen P Aromaa M Pienihaumlkkinen K Raumlihauml H Vahlberg
T Mattila ML Sillanpaumlauml M Dental fear one single clinical question for
measurement Open Dent J 2009 Jul 283(1)161-216
bull Van Wijk AJ McNeil DW Ho CJ Buchanan H Hoogstraten J A short English
version of the Fear of Dental Pain questionnaire European journal of oral sciences
2006 Jun 1114(3)204-8
bull Corah NL Development of a dental anxiety scale Journal of dental research 1969
Jul 148(4)596
bull Humphris GM Morrison T Lindsay SJ The Modified Dental Anxiety Scale
validation and United Kingdom norms Community dental health 1995
Sep12(3)143-50
bull Buchanan H Niven N Validation of a Facial Image Scale to assess child dental
anxiety International Journal of Paediatric Dentistry 2002 Jan 112(1)47-52130
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Venham L Gaulin-Kremer E Munster E Bengston-Audia D Cohan J Interval
rating scales for childrenrsquos dental anxiety an uncooperative behavior Paediatr Dent
19802195-202
bull Buchanan H Development of a computerised dental anxiety scale for children
validation and reliability British dental journal 2005 Sep 24199(6)359-62
bull Humphris GM Wong HM Lee GT Preliminary validation and reliability of the
modified child dental anxiety scale Psychological reports 1998 Dec 183(3
suppl)1179-86
bull Howard KE Freeman R Reliability and validity of a faces version of the Modified
Child Dental Anxiety Scale International Journal of Paediatric Dentistry 2007 Jul
117(4)281-8
131
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
bull Quiles JM Garciacutea GG Chellew K Vicens EP Mariacuten AR Carrasco MP
Identification of degrees of anxiety in children with three-and five-face
facial scales Psicothema 201325(4)446-51
bull Spielberger CD Manual for the State-Trait Anxiety Inventory STAI (form
Y)( self-evaluation questionnaire)
132
Thank youhellip
133
Thank youhellip
133