Association Between Dental Anxiety and Oral Health-Related Quality of Life

doi:10.21203/rs.3.rs-3929065/v1

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Association Between Dental Anxiety and Oral Health-Related Quality of Life

https://doi.org/10.21203/rs.3.rs-3929065/v1

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Objectives

this study aimed to examine the association between both parental and children’s anxiety and its impact on the Oral Health Related Quality of Life (OHRQoL) of Saudi children in Eastern Province of Saudi Arabia.

Methods

Data on 93 individuals aged of 7–12 years were collected using clinical examination and Arabic validated questionnaires of Child Oral Health Impact Profile-Short Form (COHIP-SF19) and Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS). Negative binomial regression analysis and logistic regression analysis was done to study the association between children and parental dental anxiety as well as OHRQoL while adjusting for certain confounders.

Results

Overall, our multivariate analyses showed that children with high dental anxiety (CFSS-DS ≥ 38) (p = 0.027) and higher percentage of dental caries (p = 0.013) had a significantly lower OHRQoL after adjusting for clinical and socio-demographic factors. Further, the odds of having high dental anxiety in children increased by 12.97 (95%CI: 1.29-130.77) with every one-unit increase in parental dental fear.

Conclusion

Our findings demonstrate that children’s anxiety and dental caries are both associated with poorer OHRQoL. Further, parental fear of dentists was associated with children’s fear of dentists.

Oral health-related quality of life

COHIP-SF19

CFSS-DS

Children

Dental fear

Dental experience

parents

Dental anxiety is a common concern among children and parents, with significant implications for oral health and overall well-being. ⁽¹⁾ Among the many factors related to the general well-being of an individual, oral health has been described as integral to the general well-being of an individual. ⁽²⁾ HRQoL has often been used to describe the impact of disease on the daily functioning of an individual. ⁽³⁾ The fear and uneasiness surrounding dental visits often leads to compromised oral hygiene practices and neglected dental care. ^{(4, 5)} As a result, children experience a lower quality of life in regard to oral health. ^{(4, 5)} Thus, the Oral Health-Related Quality of Life (OHRQoL) was developed to measure the impact of oral diseases on OHRQoL ⁽²⁾.

OHRQoL is assessed using a questionnaire that incorporates the physical, psychological, and social impacts of oral health. ⁽⁶⁾ There are multiple OHRQoL questionnaires that have been developed over the years. ^{(6, 7)} Some of these were targeted towards adults ⁽⁸⁾, while others were intended to measure OHRQoL in children. ^{(6, 7)} Amongst, these are the Early Childhood Oral Health Impact Scale (ECOHIS) which measures OHRQOL in children between the ages of 3–5 ⁽⁹⁾, and the Child Oral Health Impact Profile-Short Form (COHIP-SF19) ⁽¹⁰⁾ which is a shortened version of the Child Oral Health Impact Profile (COHIP) ⁽¹⁰⁾ that measures OHRQOL in children between the ages of 7–18 years of age. ^{(6–8, 10)} There are multiple factors that have been associated with lowering the OHRQoL in individuals. These factors include the age of the individual ⁽¹¹⁾, gender ⁽¹²⁾, education level ⁽⁴⁾, family income ⁽⁴⁾, geographic location ⁽⁶⁾, body-mass index (BMI) ^(13), dental caries ⁽⁴⁾, malocclusion ⁽¹⁴⁾, child’s anxiety ⁽¹⁾, and parental anxiety. ^{(15, 16)}. The general perception is that dental anxiety can lead to avoidance behaviors, resulting in a lack of regular dental care and delay in seeking necessary treatment. ⁽⁵⁾ It is also widely assumed that avoidance behavioral patterns of dental care and treatment have a detrimental effect on oral health ⁽⁷⁾. Further, these same factors such as age, gender, income, education, and dental caries are also associated with an increase in dental anxiety. ^{(17, 18)}

Dental anxiety in children can also be assessed using a questionnaire. The most used questionnaire to determine a child’s level of anxiety is the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS). ⁽¹⁹⁾ The CFSS-DS rates fear using a 5-point Likert scale in 15 dental-related situations. ⁽¹⁹⁾ While there are multiple studies conducted that examined the association between dental anxiety and OHRQoL, these studies did not take into consideration the socio-demographic and clinical factors that could have acted as confounders and affected their results. Thus, the aim of the study was to examine the association between children’s anxiety levels and OHRQoL, while adjusting for certain confounders that could have adversely affected the association between these two variables.

This cross-sectional study recruited Saudi children between the ages of 7–12 years of age and the parents of these children. Parents will include individuals who attend the IAU Dental Hospital between September 2022-February 2023.

Sample Size

Sample size calculation was done. A power calculation was performed using Stata/SE16.1 (StataCorp, College Station, TX, USA). Assuming that the difference in OHRQoL among anxious children compared to non-anxious children would differ by a mean score of 19. ⁽¹⁾ A sample size of N = 58 is adequate to obtain a type 1 error rate of 5% and a power of 80%. However, we believe this number to be too low. So, we decided that we will be using a convenience sample based on children who attend the clinic between September 2022-February 2023. We were able to collect a sample size of 93.

The inclusion criteria involved Saudi children; Arabic-speaking parents; children between the ages of 7–12 years; and good health. The exclusion criteria are non-Saudi children; non-Arabic speaking parents; children with special care needs or children with a debilitating medical condition. and refusal to give consent for enrolment in the study.

Questionnaire assessment

Informed consent

was obtained from parents as a part of our online questionnaire that asked questions related to the child's oral health-related quality of life. The questionnaire involves the Arabic-validated questionnaire of the COHIP-SF19 and the Arabic-validated questionnaire of the CFSS-DS. Further, parents' questionnaire form was used from a previous study including 5 questions involving the child’s age, parent’s age, income, education level, and smoking status was added to the survey. ^(1)(10)

Clinical examination

Participants' weight will be measured using a calibrated digital scale, height will be measured using a stadiometer. Clinical examination will be conducted using a sharp explorer, and a dental mirror. The oral examination will record Angle’s molar classification, presence of crossbite, presence of an open-bite, midline shift, and decayed teeth. Oral exam will be conducted by two examiners and inter-reliability testing will be performed.

Defining Outcomes, Exposures, and Confounders

OHRQoL: This was measured and analyzed as a count variable using the COHIP-SF 19.

Children’s Dental Anxiety: Was measured using the CFSS-DS and analyzed as a count variable and as a binary variable (CFSS-DS ≥ 38; high anxiety). ⁽²⁰⁾

Parent’s fear of dentists: Measured using a 5-point Likert Scale. However, it was analyzed as a continuous variable.

Parent’s previous bad experience: Measured as a binary variable where they answered “yes/no” to “if they had ever had a previous bad experience with a dentist when they were a child.”

Parent’s comfort at the last visit to the dentist: Measured as a binary variable where they answered, “comfortable/anxious”.

Caries Percentage: Percentage of caries was calculated as the number of carious primary and permanent teeth divided by the total number of primary and permanent teeth.

Child’s age: Was measured as a continuous variable.

Child’s sex: Was measured as a binary variable (male/female).

Education: Was measured as a categorical variable (less than high school; high school; more than high school).

Family Income: Was measured as a categorical variable (low: <9,000 Saudi Riyals (SAR); medium: 9,000-12000 SAR; high > 12,000 SAR) ⁽²¹⁾.

Parental Smoking: Was measured as a categorical variable (never smoked; former smokers; current smokers) ⁽²²⁾.

Child’s Weight Category: Measured as a categorical variable. Calculated using the World Health Organization (WHO) criteria. Underweight: BMI is less than or equal to -2; Normal: BMI is greater than − 2 and less than 1; Overweight: BMI is greater than or equal to 1 and less than 2; Obese: BMI is greater than or equal to 2. ⁽²³⁾

Ethical Considerations

The research ethical approval (IRB-2022-02-379) was obtained from the Deanship of Scientific Research, Imam Abdulrahman Bin Faisal University, Dammam. Participation in the study was voluntary, and they were ensured of anonymity, privacy, and confidentiality of their data. The purpose, details, and expected benefits of the study were explained to all participants. Ethical guidelines expressed in the Declaration of Helsinki were followed during the conduct of the study.

Statistical Analysis

Descriptive statistics (means and standard deviations) were reported. Unpaired t-tests were used to compare the difference in means among the two groups. One-way analysis of variance (ANOVA) was used to analyze differences in means among three or more groups. A univariate negative binomial regression analysis was used to study the association between COHIP-SF 19 and age; COHIP-SF 19 and caries percentage; CFSS-DS and age; CFSS-DS and caries percentage. Parental fear of dentists was measured using a 5-point Likert scale and was analyzed as a continuous variable. When CFSS-DS was used as a count outcome a negative binomial regression analysis was conducted. However, when CFSS-DS was used as a binary outcome, a logistic regression analysis was done. We performed an adjusted negative binomial regression analysis to examine the association between OHRQoL (COHIP-SF19) and children’s dental anxiety (CFSS-DS). An adjusted negative binomial regression analysis was used to examine the association between children’s dental anxiety (CFSS-DS) and parental anxiety (parent's fear of dentists; parent’s previous bad experience at the dentist when they were a child; parent’s comfort during their last visit at the dentist). An adjusted logistic regression analysis was used to study the association between high levels of children’s dental anxiety (CFSS-DS) and parental anxiety (parent's fear of dentists; parent’s previous bad experience at the dentist when they were a child; parent’s comfort during their last visit at the dentist). For all multivariable regression analyses, independent variables included child’s age, sex, presence of any medical conditions, parents’ education level, parents smoking status, family income, patient’s weight category, presence of malocclusion, and caries percentage. For both negative binomial regression models, we reported the coefficient and 95% confidence interval (95% CI). We selected the negative binomial regression since the distribution of these dependent count variables exhibited over-dispersion. For the logistic regression analysis, we reported the adjusted odds ratio and 95% confidence interval. A P-value of 0.05 was used to evaluate the significance of all the models in the study. We used Stata/SE16.1 (StataCorp, College Station, TX, USA) to analyze the data.

Table 1 summarizes the sociodemographic characteristics of children ages 7–12 years and their parents who completed the surveys and the clinical examination. Overall, 93 participants have completed both surveys and clinical examinations. There was an almost equal number of male (53.8%) and female children (46.2%) who participated in the study. A higher child’s age was significantly associated with a higher CFSS score. A total of 32.3% of the children were either overweight or obese. A higher caries percentage was significantly associated with a higher COHIP-SF19 score (poorer OHRQoL) and a higher CFSS-DS score (higher dental anxiety in children). Figure 1 also shows that children who were accompanied by their mothers had a higher CFSS-DS score than those who were accompanied by their fathers. This value was tested using an independent t-test and the difference between them was statistically significant (p = 0.021).

Table 1

Demographics of Saudi children between the ages of 7–12 years and their parents who have completed the Child Oral Health Impact Profile Short Form (COHIP-SF 19) and Children’s Fear Survey Schedule – Dental Subscale (CFSS-DS). N = 93
	Overall number (%)	COHIP-SF19 (SD)	P-Value*	CFSS-DS (SD)	P-Value*
Total	93 (100%)	16.48 (11.10)		27.40 (11.33)
Age (mean)	9	--	0.754	--	0.020*
Sex
Male	50 (53.8%)	17.30 (9.03)	0.447	25.56 (10.79)	0.092
Female	43 (46.2%)	15.53 (13.15)	0.447	29.53 (11.69)	0.092
Child Medical Conditions**
Yes	4 (4.3%)	16.78 (11.23)	0.217	27.78 (11.38)	0.130
No	89 (95.7%)	9.75 (4.11)	0.217	19.00 (6.16)	0.130
Parental Education
Less than high school	8 (8.6%)	12.5 (11.40)	0.569	29.38 (12.60)	0.529
High school	27 (29.0%)	16.63 (10.66)		29.04 (14.24)
More than high school	58 (62.4%)	16.97 (11.80)		26.36 (9.61)
Parental Smoker
Never	76 (81.7%)	15.78 (9.86)	0.050	27.17 (11.14)	0.357
Current	15 (16.1%)	21.67 (15.28)		29.80 (12.62)
Former	2 (2.2%)	4.5 (6.36)		18.00 (0.00)
Family Income†
Low	31 (33.3%)	17.26 (10.63)	0.403	27.84 (11.64)	0.141
Medium	19 (20.4%)	18.79 (12.30)		31.42 (14.40)
High	43 (46.2%)	14.91 (10.90)		25.30 (9.13)
Child Weight Category‡
Underweight	6 (6.5%)	10.17 (6.74)	0.449	24.67 (6.50)	0.836
Normal	57 (61.3%)	16.40 (9.92)		27.05 (12.09)
Overweight	12 (12.9%)	16.67 (11.58)		27.67 (10.23)
Obese	18 (19.4%)	18.72 (14.93)		29.22 (11.24)
Caries Percentage (mean) §	13.45	--	0.008*	--	0.001*
SD - Standard Deviation
COHIP-SF 19 - Child Oral Health Impact Profile Short Form
CFSS-DS - Children’s Fear Survey Schedule – Dental Subscale
* When groups contained only two categories, an independent paired t-test was performed. When groups contained three or more categories a one-way analysis of variance (ANOVA) was performed. When the independent variable was continuous (age/caries percentage) a univariate negative binomial regression was used. P-value < 0.05 indicates a statistically significant difference.
** Child medical conditions consisted of the presence of any chronic medical condition. Special needs patients were, however, excluded from the study.
† Family income was defined according to the XX
‡ Calculated using the World Health Organization (WHO) criteria. Underweight: BMIz is less than or equal to -2; Normal: BMIz is greater than − 2 and less than 1; Overweight: BMIz is greater than or equal to 1 and less than 2; Obese: BMIz is greater than or equal to 2.
§ Percentage of caries was calculated as the total number of carious primary and permanent teeth divided by the total number of primary and permanent teeth.

Overall, our multivariate analyses (Table 2) showed that with every one-unit increase in children’s level of dental anxiety (CFSS-DS) their OHRQoL decreased by 0.013 (95%CI: 0.001–0.026) and this value was statistically significant (p = 0.037). Further, children with high dental anxiety (CFSS-DS ≥ 38) had a lower OHRQoL (Coef.:0.442; 95%CI: 0.050–0.835). This is depicted using a box plot in Fig. 2. Lower OHRQoL was also associated with the percentage of caries, in which every one unit increase in the percentage of caries, the OHRQoL worsened by 0.014 (95% CI: 0.003–0.025) and this value was statistically significant (p = 0.013). Finally, parental fear of dentists was not associated with poorer OHRQoL after adjusting for child’s age, sex, presence of any medical conditions, parents’ education level, parents smoking status, family income, patient’s weight category, presence of malocclusion, and caries percentage.

Table 2

Negative binomial regression analysis studying the association between Child Oral Health Impact Profile Short Form (COHIP-SF 19) with Children’s Fear Survey Schedule – Dental Subscale (CFSS-DS), percentage of caries, and parental fear of dentists after adjusting for child’s age, sex, presence of any medical conditions, parents’ education level, parents smoking status, family income, patient’s weight category, presence of malocclusion, and caries percentage. (N = 93)
Exposure/Outcome	COHIP-SF19
	Adjusted Coef.	95% CI	P-Value
CFSS-DS (Continuous)	0.013	0.001–0.026	0.037*
CFSS-DS (Reference: Low) **	0.442	0.050–0.835	0.027*
Percentage of Caries †	0.014	0.003–0.025	0.013*
Parental Fear of Dentist ‡	0.097	-0.006-0.200	0.064
Parent’s Previous Bad Experience ¶	0.069	-0.291-0.429	0.708
Parent’s Last Visit §	0.174	-0.103-0.450	0.219
95% CI: 95% Confidence Interval
COHIP-SF 19 - Child Oral Health Impact Profile Short Form
CFSS-DS - Children’s Fear Survey Schedule – Dental Subscale
Coef. - Coefficient
*p-value < 0.05 and this value is statistically significant
** Analyzed as a binary variable. CFSS ≥ 38 = High
† Percentage of caries was calculated as the number of carious primary and permanent teeth divided by the total number of primary and permanent teeth. Adjusted for child’s age, sex, presence of any medical conditions, parents’ education level, parents smoking status, family income, patient’s weight category, presence of malocclusion, and child’s anxiety (CFSS-DS)
‡ Measured using a 5-point Likert scale. Analyzed as a continuous variable.
¶ Measured as a binary variable where they answered “yes/no” to “if they had ever had a pervious bad experience when they were a child with a dentist.”
§ Measured as a binary variable where they answered, “comfortable or anxious or higher” to “how was your last experience with your visit to the dentist.”

Table 3 depicts the negative binomial regression analyses on children’s level of dental anxiety by parental levels of dental fears and previous experiences. With every one-unit increase in the parental fear of dentists, the CFSS-DS score increased by 0.185 (95%CI: 0.146–0.224) and this value was statistically significant (p < 0.001). Figure 3 depicts a boxplot showing how CFSS-DS score increases gradually as the parent’s fear of dentists increases. Finally, parents who answered that they were anxious on their last visit to the dentist had children with higher levels of dental anxiety (Coef.:0.217; 95%CI: 0.068–0.367). The logistic regression analysis results also showed that the odds of having high dental anxiety in children increased by 12.97 (95%CI: 1.29-130.77) with every one-unit increase in parental fear of dentists.

Table 3

Negative binomial regression analysis studying the association between Children’s Fear Survey Schedule – Dental Subscale (CFSS-DS) with parental fear of dentists after adjusting for child’s age, sex, presence of any medical conditions, parents’ education level, parents smoking status, family income, patient’s weight category, presence of malocclusion, and caries percentage. (N = 93)
Exposure/Outcome	CFSS-DS
	Adjusted Coef.	95% CI	P-Value
Parental Fear of Dentists†	0.185	0.146–0.224	< 0.001
Parent’s Previous Bad Experience ‡	0.126	-0.067-0.319	0.202
Parent’s Last Visit ¶	0.217	0.068–0.367	0.004*
95% CI: 95% Confidence Interval
CFSS-DS - Children’s Fear Survey Schedule – Dental Subscale
*p-value < 0.05 and this value is statistically significant
† Measured using a 5-point Likert scale. Analyzed as a continuous variable.
‡ Analyzed as a binary variable where they answered “yes/no” to “if they had ever had a pervious bad experience with a dentist when they were a child.”
¶ Analyzed as a binary variable where they answered, “comfortable or anxious or higher” to “how was your last experience with your visit to the dentist.”

In our cross-sectional study involving 93 participants aged 7–12, we examined the relationships between dental anxiety in both children and their parents and children's OHRQoL. Our study findings revealed that a higher caries percentage was significantly associated with a higher COHIP-SF19 score (poorer OHRQoL) and a higher CFSS-DS score (higher dental anxiety in children). Also, parental dental anxiety does not show a strong association with a child’s OHRQoL. However, increased parental dental anxiety had a significant impact on increased CFSS-DS scores, leading to poorer OHRQoL.

Our study's results align with existing global research demonstrating the adverse effect of dental anxiety on OHRQoL. This correlation has been observed in various countries, such as Canada ⁽²⁴⁾, the Netherlands ⁽²⁵⁾, Hong Kong ⁽²⁶⁾, Egypt ⁽²⁷⁾, Switzerland ⁽²⁸⁾, Sweden ⁽²⁹⁾ and Malaysia ⁽³⁰⁾. However, it's worth noting that in Swedish study ⁽²⁹⁾ on adults, the authors did not find a statistically significant relationship between OHRQoL and dental anxiety, highlighting the need for further examination of cultural and regional variations in this relationship.

The OHRQoL was significantly associated with the percentage of caries. A higher caries percentage was associated with a higher COHIP-SF19 score (poorer OHRQoL). Other studies in Brazil ⁽³¹⁾, Indonesia ⁽³²⁾, and China ⁽³³⁾ showed the same relation between the OHRQoL and caries.

Our result showed that parental dental anxiety children who visited the dentist with their mother had higher CFSS-DS scores than those who came with their father. However, parental fear of dentists was not associated with poorer OHRQoL. Another study showed only the parent distress domain was influenced by maternal anxiety showing that anxious mothers tend to report feeling guilty or upset because of children’s dental problems or treatment experience. ⁽³⁴⁾ Higher stress levels from the mothers could be related to their oral health problems. As they have poor dental experience, they don’t want their children to have the same experience.

Implications & future directions:

The association between dental anxiety and OHRQoL, as observed in our study, has important implications for pediatric dentistry in Saudi Arabia. Understanding this link can inform strategies for addressing dental anxiety in children, leading to improved OHRQoL and overall well-being. This could include the development of interventions and programs focused on reducing dental anxiety in pediatric patients.

The study findings have practical applications for dental practitioners in Saudi Arabia. Identifying children with dental anxiety and addressing their concerns can lead to improved OHRQoL and may involve collaboration with parents to provide a supportive environment for dental visits.

Limitations:

While our study provides valuable insights into the relationships between dental anxiety, OHRQoL, and caries risk in Saudi Arabian children, it is essential to acknowledge the limitations that may affect the interpretation and generalizability of our findings. The cross-sectional study design restricts our ability to establish causality, and convenient sampling might introduce selection bias. Future research could benefit from longitudinal designs to provide a more robust understanding of the relationships observed in our study.

Another limitation is the use of a convenient sample. The sample may not be fully representative of the broader population of Saudi Arabian children, potentially introducing selection bias. As a result, the generalizability of our findings to all children in the country may be limited. Future studies should aim for larger, more diverse, and more representative samples.

In conclusion, our study highlights the significant impact of dental anxiety on Saudi Arabian children's oral health-related quality of life (OHRQoL) and the association between caries risk and OHRQoL. Parental dental anxiety's influence on children's anxiety underscores the need for parental education and support. These findings are in line with global research, emphasizing the universal relevance of addressing dental anxiety and caries risk in pediatric dental care. Future directions should focus on longitudinal studies, cultural considerations, and tailored interventions. Practically, early intervention, preventive measures, parental support, and child-friendly dental environments are essential for improving oral health outcomes in Saudi Arabian children.

Survey Questions

Consent

Informed consent was obtained from parents as a part of our online questionnaire that asked questions related to the child's oral health-related quality of life.

Data Availability Statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Funding

This research received no external funding.

Conflict of interest disclosure

The authors declare no conflict of interest.

Ethics approval statement and consent to participate

Ethical approval was obtained from the Research Ethics Committee, Faculty of Dentistry, Imam Abdulrahman bin faisal University.

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No competing interests reported.

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Association Between Dental Anxiety and Oral Health-Related Quality of Life

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