Introduction
Dental anxiety and phobia are known barriers to receive regular dental care in many anxious patients [
1]. Dental anxiety or fear is common among children seeking dental treatment [
2‐
4]. Severe dental anxiety and fear in children attending dental clinics will not only lead to the failure of the normal process of dental treatment but also lay a psychological shadow for adult dental anxiety and fear [
5‐
7]. Timely detection and appropriate intervention can shorten the time and frequency of treatment and help relieve the economic and psychological burden of patients because prolonged or multiple services require more time or cost and, importantly, may result in painful memories for the children and parents. Therefore, how identifying patients' dental anxiety or fear in advance, especially in children, determining its degree, and analyzing the factors affecting dental anxiety are particularly important.
Questionnaire-based assessment of dental anxiety is the most commonly used method of dental anxiety assessment in pediatric patients [
5]. However, given that many children cannot express their dental anxiety clearly and that nearly all children require parents to visit the dental clinic, there are at least two types of dental anxiety for elementary school students who are not very expressive, i.e., children’s self-reported and parents’ reported dental anxiety. Meanwhile, there are few international studies on whether there is a difference between children's self-reported and their parents’ proxy-reported dental anxiety [
1]. In the process of dental visits, parents of children with dental anxiety may underestimate or overestimate the state of children with dental anxiety, so it may harm the process of dental visits and the mental health of children [
1,
8], especially for underestimation risk, given that a consequence of the underestimation is the risk of overlooking some children’s needs for special attention, and therefore, they will suffer from a higher degree of dental fear [
8]. Therefore, identifying which types of dental anxiety can reflect the true dental anxiety of children themselves is important. Additionally, analyzing the influencing factors of true dental anxiety (self-reported or parent-reported) is reasonable because carrying out targeted interventions based on these factors is beneficial to the management of dental anxiety in children and even their oral and mental health in their adult life. In the current study, we first investigated the interrater agreement between children’s self-reported and their mothers’ proxy-reported dental anxiety and then explored the potential factors of children’s dental anxiety.
Discussion
Dental anxiety is common among children and adults seeking treatment in dental clinics. In the current study, a new scale was developed by combining the MDAS and FIS (MDAS-FIS). Additionally, the current study found that children’s self-reported dental anxiety is commonly underestimated by their mothers’ proxy-reported dental anxiety during dental visits, and with increasing age, the degree of dental anxiety in children gradually decreases, and the presence of mothers during dental visits can alleviate dental anxiety in children.
In dental clinics, timely detection and appropriate intervention can shorten the time and frequency of seeking treatment and help relieve the economic and psychological burden of patients [
4,
7,
12‐
16]. As early as 1968, Corah et al. designed a questionnaire to evaluate the levels of dental anxiety, namely, the Corah Version of the Dental Anxiety Scale (CDAS) [
17,
18]. Four questions were designed for the CDAS, while five questions were designed for the MDAS in 1995 [
9]. The first four questions of the two scales were consistent (Table
1) [
9]. The fifth problem of MDAS involves local anesthesia injection because it is a common concern and even anxiety among patients attending the department of stomatology [
9]. Both the CDAS and MDAS were initially used for the assessment of dental anxiety in adults, and then a large number of studies gradually began to apply them to the study of dental anxiety in children. Many studies have found that MDAS has good predictive effects in both adults and children [
5,
6].
The FIS includes five images, ranging from very sad (very worried) to very happy (relaxed or not worried) [
10]. FIS is used to detect the anxiety state of children attending hospitals and can be used as a single detection method in clinical studies [
10,
19‐
22]. In addition, several studies have used FIS to describe the anxiety state of MCDAS and CDAS, i.e., from 1 to 5 representing no anxiety to very anxiety of MCDAS and CDAS, respectively [
23‐
27]. Therefore, we combined the MDAS with the FIS to detect dental anxiety in both children and their mothers in the current study.
Previous studies have suggested that children aged 8 and above can accurately express their physical and mental discomfort [
28]. However, many studies have found that children aged 3–4 can communicate physical and mental experiences, such as pain. [
29,
30]. The children included in this study were all primary school students in Zhengzhou City, with a minimum age of 6 years, a maximum age of 12 years, and a median age of 8.5 (7.0–10.8) years, which met the age requirements of previous studies.
Although there are many international studies on dental anxiety in children [
2,
5,
6], there are relatively few studies on the difference between children’s self-reported and parents’ proxy-reported dental anxiety [
1,
8,
26]. Limited studies suggest that the reliability of parents’ proxy-reported dental anxiety is poor and cannot replace children's self-reported dental anxiety; that is, the consistency between the two is poor [
6,
31,
32]. In 2015, a study found that parents’ proxy-reported dental anxiety underestimated 46% of children's self-reported dental anxiety in the UK [
1]; the results of this study suggest that more attention should be given to the screening of children's self-reported dental anxiety. In addition, from a macro perspective, children's self-reporting of a clinical problem is conducive to a more accurate assessment of the incidence, risk factors and clinical manifestations of the clinical problem in children to facilitate subsequent prevention and treatment strategies [
6].
In this study, it was found that MDAS-Question 5 was the item with the highest consistency of children’s self-reported and mothers’ proxy-reported dental anxiety, regardless of the scores and hierarchies (degrees or stratifications), but only moderate consistency, followed by MDAS-Question 3, with the only general agreement (Table
4). MDAS-Question 1 was the item with the lowest consistency (Table
4). The results of this study suggest that even on MDAS-Question 5 with the best consistency, mothers’ proxy-reported dental anxiety underestimates children’s self-reported dental anxiety by 43% (Table
4). In terms of dental anxiety stratification (hierarchy), the consistency was worse, and there was no significant difference (Table
5). This study highlights the importance of early detection and early intervention of children’s self-reported dental anxiety.
The reason for the difference between children’s self-reported and mothers' proxy-reported dental anxiety is unclear. Our clinical observations suggest that this may be related to the cognitive differences between children and their mothers in dental diagnosis and treatment or may be due to their mothers' overoptimistic assessment of their children's dental diagnosis and treatment performance. In addition, it is not known whether the differences between children's self-reported and their mothers' proxy-reported dental anxiety gradually decrease as children age. If the answer is yes, it may be understood that the difference between children's self-reported and parents’ proxy-reported dental anxiety is due to the children's low awareness of dental care, since parental awareness generally does not fluctuate greatly.
Notably, the current study has originality and significance compared with previous studies [
1,
8,
26]. First, the ages of the study children were the youngest, and the median or mean ages of the children in the other three studies were approximately 10 years or above. Second, the measurement scales are different from each other. Our study employed a sample and a suitable scale, i.e., MDAS-FIS, and the other three studies employed the Children’s Fear Survey Schedule (15 items) and Modified Child Dental Anxiety Scale-faces version (6 items). Third, we not only checked the interrater agreement of the items but also tested the interrater agreement of the hierarchies (degrees or stratifications); the other studies only performed one of them. Fourth, we investigated the factors affecting children’s dental anxiety in the same cohort of children simultaneously, and other studies did not perform this investigation. Regardless of the differences, our study combined with previous studies has a similar finding that the interrater agreement between children’s self-reported and their mothers’ proxy-reported dental anxiety is poor, which indicates that children’s self-reported dental anxiety is relevant and that mothers’ proxy-reported dental anxiety is an important supplement.
However, there are some limitations in this study. First, family socioeconomic status was not investigated. Different socioeconomic conditions could lead to various understandings of MDAS questions in children and their mothers. Notably, all participants were urban primary school students, and all their parents had decent jobs in Zhengzhou City. The favorable cognitive ability and representativeness of the participants can largely reduce the potential bias of the socioeconomic conditions. Second, we only enrolled mothers rather than the fathers of children in this study because we found that mothers were more approachable to their children during the elementary study period, and more than 90% of accompanying dental visits were performed by only mothers in real-life dental practice. Therefore, we do not know whether the findings would be different if the mothers were replaced by the fathers. Third, many patients were excluded from the study according to the study design, and the effect on the findings of the study is unknown; however, the finally enrolled participants were more homogeneous to draw a valid conclusion. Last, given that the sample size of this study is small, we did not score dental anxiety as a scale but on a continuum and performed linear regressions rather than logistic regressions; future large sample size studies using linear regression are warranted.
In conclusion, the prevalence of children’s self-reported dental anxiety is generally underestimated by their mothers; children should be encouraged to test their dental anxiety by scales (such as the MDAS-FIS) by themselves before dental diagnosis and treatment to facilitate early detection and intervention. Additionally, maternal presence during dental visits is strongly recommended for children.
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