Determining the relationship between perceived stress and dental anxiety in children aged 8-11 perceived stress and dental anxiety

Authors

Abstract

AimThis study aims to determine the relationship between perceived stress and dental anxiety in children aged 8-11.
MethodsThe Perceived Stress Scale (PSS) and the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) were administered face-to-face to children aged 8-11 who visited the faculty for the first time. Normality was assessed using the Shapiro-Wilk test. If normal distribution was not present, the Mann-Whitney U test or Spearman correlation test was applied. The significance level was set at p=0.05.
ResultsThe study included 266 children, with 42.5% male and 57.5% female participants. The majority of the children (55.6%) were in the 8-9 age range, while 44.4% were in the 10-11 age group. The average age was 9.4 ± 1.1 years. The mean total score of the PSS was 16.5 ± 8.6, and the mean total score of the CFSS-DS was 33.2 ± 11.0. A significant positive correlation was found between PSS and CFSS-DS (Spearman’s rho=0.26, p<0.05).
ConclusionIt was concluded that as the level of perceived stress in children increases, dental anxiety also increases. Creating a calm and happy environment before treatment and approaching the treatment in a calming manner might help reduce dental anxiety in children visiting the dentist for the first time.

Keywords

Introduction

Any internal or external stimulus that creates a biological response is defined as stress. Stress leads to excessive tension, hyperarousal, and discomfort.¹ Perceived stress refers to the feelings or thoughts an individual has regarding how much stress they are under during a specific period.² Although perceived stress in children is a widely used term in the literature, it is not sufficiently defined and is associated with adverse health outcomes throughout life.³ Physical or environmental factors that trigger perceived stress in children can alter brain chemistry, with effects extending into adulthood.⁴

A study in the literature has linked perceived stress with dental anxiety. While the relationship between perceived stress and dental anxiety has been demonstrated, it has not yet been comprehensively studied.⁵ Fear and anxiety towards the dentist and dental treatment are seen as significant factors leading to avoidance of oral and dental care. Fear is a response to a known or perceived threat or danger, whereas dental fear is a reaction to threatening stimuli related to dental situations. Anxiety is described as an emotional state that occurs before encountering threatening stimuli. Negative or traumatic experiences, anxious family members, peers, or personality traits during childhood can cause dental anxiety.⁶ Dental anxiety is a cycle of persistent and excessive fear of stimuli during dental procedures, leading to the avoidance of dental treatments and resulting in dental health problems.^7,8
Understanding dental anxiety in children early and planning a solution for dental health issues can prevent the delay of treatments.^7,9 Dental anxiety has been evaluated as a public health problem, and it has been suggested that special attention should be given to patients with dental anxiety due to its negative effects on oral health.⁷ This is because avoidance of dental examination and treatment due to dental anxiety negatively impacts oral health.⁸ The negative impact on oral health indirectly affects quality of life.¹⁰ Patients with anxiety usually seek dental treatment in emergencies or when they experience toothache, leading to the skipping of primary care.¹¹
Considering all this information, the purpose of this study is to investigate the relationship between perceived stress and dental anxiety in children who have never had dental treatment before. The null hypothesis (H₀) is that there is no relationship between perceived stress and dental anxiety, while the alternative hypothesis (H₁) is that there is a relationship between perceived stress and dental anxiety.

Materials and Methods

Sample Size
The effect size was calculated using G Power 3.0.10 software (University Kiel, Germany). No previous studies have examined the relationship between perceived stress levels and dental anxiety in pediatric dental treatments. Assuming dental anxiety data is categorized as present/absent and stress levels as ordinal data, a Mann–Whitney U test planned for an effect size of 0.5 with 80% power indicated that a minimum of 134 individuals would be needed. The study included 266 children (153 girls and 113 boys) aged 8–11 who were visiting the Pediatric Dentistry Department of Recep Tayyip Erdoğan University Faculty of Dentistry for the first time.
Inclusion Criteria
– Not having any systemic disease
– Not presenting with severe symptoms such as trauma, acute apical abscess, or pain
– No syndrome
– No prior dental treatment experience
– Children aged 8–11 who voluntarily participated
Exclusion Criteria
– Children with systemic disease
– Presenting with acute symptoms like trauma, pain, or acute apical abscess
– Having any syndrome
– Prior dental treatment experience
– Not consenting to participate
– Not within the age range of 8–11 years
Study Design
Children included in the study were administered the Perceived Stress Scale (PSS) face-to-face, validated by Oral et al.¹² The unidimensional scale consists of 9 items rated on a 4-point Likert scale.^2,13 The Cronbach’s alpha internal consistency reliability coefficient was found to be 0.76, and the test–retest correlation was 0.79. According to the PSS instructions, the child was asked to respond based on how well each item applied to them in the past week. Higher scores on the scale indicate higher levels of perceived stress. The total scores range from 0 to 27.²
Subsequently, the child was administered the Children’s Fear Survey Schedule–Dental Subscale (CFSS-DS).¹⁴ face-to-face. The CFSS-DS is a scale measuring dental anxiety related to dentist visits and treatments. The Turkish validity and reliability study was conducted by Seydaoğlu et al.¹⁵ Each item was scored between 1 and 5 based on the response (1 = Not at all, 2 = A little, 3 = Fairly, 4 = Quite a lot, 5 = Very much). The total score ranges from 15 to 75, with children scoring 38 and above on the CFSS-DS defined as having dental anxiety.¹⁴ The questionnaire was administered face-to-face in the waiting room before the examination, and the demographic data of the children were recorded in the scale file.
Ethical Approval
The study received ethical approval from the Non-Interventional Clinical Research Ethics Committee of Recep Tayyip Erdoğan University, Faculty of Medicine (Date: 16.03.2023, Decision No: 2023/79). Informed consent was obtained from both parents and children before the study.
Statistical Analysis
The statistical analysis was conducted using Jamovi version 2.3.28. Descriptive analysis was conducted, and variables were presented using the median (min–max) format. Normality was assessed using the Shapiro–Wilk test. If the data did not follow a normal distribution, either the Mann–Whitney U test or Spearman’s correlation test was conducted. The significance level was set at p=0.05.

Results

The demographic characteristics of the participants are presented in Table 1. The study included a total of 266 children, comprising 113 males (42.5%) and 153 females (57.5%). The majority of the children (55.6%) were aged between 8 and 9 years, while 44.4% were aged between 10 and 11 years. The average age of the children was 9.4 ( ± 1.1) years. The mean total score on the Perceived Stress Scale (PSS) was 16.5 ( ± 8.6), and on the Children’s Fear Survey Schedule–Dental Subscale (CFSS-DS), it was 33.2 ( ± 11.0) (Table 1).
The comparison of the PSS with age and gender in this study is shown in Table 2. There was no significant difference in perceived stress scale scores between genders or age groups (p>0.05). However, children aged between 10 and 11 scored higher on the 9th question compared to those aged between 8 and 9 (p<0.05) (Table 2).
The relationship between the CFSS-DS scale and age and gender in this study is shown in Table 3. There was no significant difference between genders in terms of the CFSS-DS total score or any of the questions (p>0.05). However, children in the 8–9 age group scored significantly higher on the 3rd question “Fear of getting an injection” and the 12th question “Fear of something going down their throat” compared to the 10–11 age group (p<0.05). There were no significant differences in the remaining questions (p>0.05) (Table 3).
A significantly positive correlation was found between PSS and CFSS-DS scores (p<0.05) (Figure 1).

Discussion

In the present study, the effect of behavioral changes due to perceived stress on dental anxiety was investigated in children aged 8–11. According to this study’s results, as perceived stress increased, dental anxiety also increased. That is, as PSS scores increased, CFSS-DS scores also increased, and there was a statistically significant relationship between them. In this study, the average PSS was 16.5 ( ± 8.6), while the average CFSS-DS was 33.2 ( ± 11.0). No significant relationship was found between the PSS and CFSS-DS scales and genders. When comparing the total CFSS-DS scores of the 8–9 and 10–11 age groups, a statistically significant relationship was found between them. Considering these findings, the null hypothesis (H₀) stating there is no relationship between perceived stress and dental anxiety was rejected. The data from the presented study support the alternative hypothesis (H₁), which highlights a relationship between perceived stress and dental anxiety.
According to Davis and Turner-Cobb’s study, girls perceive stress more than boys.¹³ Another study involving adults reported that perceived stress was higher in women.¹⁶ It is suggested that women show higher emotional development and significantly higher awareness in understanding and expressing emotions compared to men.¹⁷ In the current study, no significant difference was found in perceived stress levels between girls and boys. The higher number of girls in this study might explain the close mean perceived stress levels between genders.
Studies in the literature have reported that gender affects dental anxiety.^5,18 In a study by Alvaselo et al. conducted on Finnish children, the average dental fear scores of girls were calculated as 23.2 ( ± 6.9), slightly higher than boys.¹⁸ Similarly, another study investigating the relationship between dental anxiety and gender found that anxiety levels in women were significantly higher than in men.⁵ Additionally, while one study reported that dental anxiety was higher in boys,¹⁹ another study found no significant difference in dental anxiety levels between boys and girls.²⁰ In the current study, no significant difference was found between CFSS-DS scores and genders.
Davis and Turner-Cobb, in a study using the PSS scale, reported that age is not a factor for stress.¹³ Similarly, White, in a study using the PSS to determine stress in children, reported no differences between ages.²¹ In the current study, no significant difference was found between the average PSS scores of the “8–9” and “10–11” age groups. Only the children aged “10–11” scored significantly higher on the PSS question “Were you easily upset last week?” compared to children aged “8–9.” Additionally, the PSS scores of children aged “10–11” were higher than those of children aged “8–9,” but the difference was not significant.
In the literature, a study on the relationship between age and dental anxiety in adults found that dental anxiety decreases with increasing age.²² In a study by Yahyaoğlu et al., the average CFSS-DS scores of children aged “6–8” were found to be higher than those of children aged “9–12.”²³ It was reported that the reason for the decrease in dental anxiety with increasing age is that children learn to cope with the situation.⁷ In a study by Khanduri et al., evaluating CFSS-DS scores of children aged 4–14, children in the “4–7” age group had the highest anxiety scores, indicating that anxiety decreases with increasing age.¹⁴ In a study by Raj et al., measuring dental anxiety using CFSS-DS in children visiting a dentist for the first time, it was found that dental anxiety decreased with increasing age. Children reported being most afraid of “getting an injection” and “the sound of the dentist’s drill,” followed by “something going down their throat and not being able to breathe,” and least afraid of “doctors.”⁷ In the current study, children reported being most afraid of “something going down their throat and not being able to breathe,” followed by “getting an injection.” No significant difference was found between CFSS-DS scores and age in this study.
In studies on stress in the literature, Davis and Turner-Cobb¹³ found the average PSS score to be 26.34, and White²¹ found the average PSS score to be 11.73. There are not many studies in the literature reporting the average stress levels of children. One study reported the average CFSS score as 28.1.⁹ Similarly, Khanduri et al. found the average CFSS-DS score to be 28.18 ( ± 11.21).¹⁴ In a study on English children, the average CFSS score was 37.0.²⁴ Barauskas et al. reported a positive significant relationship between PSS and dental anxiety in their study on dental anxiety and stress.⁵ In this study, the average PSS score was 16.5 ( ± 8.6), and the average CFSS-DS score was 33.2 ( ± 11.0), and a positive correlation was found between them. It has been reported that dental anxiety is related to the frequency of dental visits and negative experiences during previous treatments.²⁵ The fact that the children participating in the study had no previous dental treatment experience may have led to lower perceived stress levels.
There are some limitations to the study. The inclusion criteria of our study may have resulted in a relatively small sample size, as children aged 8–11 years old who had their first dental experience were required. This is because the vast majority of these school-aged children who applied to our clinic had dental experience once in their lives. Multicenter studies can be conducted in different age groups, with larger sample sizes and where socioeconomic and cultural diversity are not limited. In the future, conducting studies on larger populations where past experiences are questioned will contribute to the literature.

Conclusion

The limitations of the presented study include working with a specific region and a limited number of children. According to this study’s results, it was determined that as the perceived stress levels of children increased, their dental anxiety also increased. Based on the study results, we can say that implementing approaches to reduce perceived stress in children receiving dental treatment for the first time, such as creating a calm and happy environment before treatment, is predicted to reduce dental anxiety and improve the quality of dental treatment for both the child and the dentist.

Declarations

References

1. Yaribeygi H, Panahi Y, Sahraei H, Johnston TP, Sahebkar A. The impact of stress on body function: a review. EXCLI J. 2017;16:1057. doi:10.17179/excli2017-480
   Article PubMed Google Scholar
2. Snoeren F, Hoefnagels C. Measuring perceived social support and perceived stress among primary school children in the Netherlands. Child Indic Res. 2014;7:473-486.
   PubMed Google Scholar
3. Davis SL, Soistmann HC. Child’s perceived stress: a concept analysis. J Pediatr Nurs. 2022;67:15-26. doi:10.1016/j.pedn.2022.07.013
   Article PubMed Google Scholar
4. Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1).
   PubMed Google Scholar
5. Barauskas I, Barauskienė K, Janužis G. Dental anxiety and self-perceived stress in Lithuanian University of Health Sciences hospital patients: a cross-sectional study. Stomatologija. 2019;21(2):42-46.
   PubMed Google Scholar
6. Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016;8:35-50. doi:10.2147/ccide.s63626
   Article PubMed Google Scholar
7. Raj S, Agarwal M, Aradhya K, Konde S, Nagakishore V. Evaluation of dental fear in children during dental visit using Children’s Fear Survey Schedule-Dental Subscale. Int J Clin Pediatr Dent. 2013;6(1):12-15. doi:10.5005/jp-journals-10005-1178
   Article PubMed Google Scholar
8. Shindova MP, Belcheva AB. Dental fear and anxiety in children: a review of the environmental factors. Folia Med (Plovdiv). 2021;63(2):177-182. doi:10.3897/folmed.63.e54763
   Article PubMed Google Scholar
9. Akbay Oba A, Dülgergil ÇT, Şaroğlu Sönmez I. Prevalence of dental anxiety in 7- to 11-year-old children and its relationship to dental caries. Med Princ Pract. 2009;18(6):453-457. doi:10.1159/000235894
   Article PubMed Google Scholar
10. Carrillo-Diaz M, Crego A, Romero-Maroto M. The influence of gender on the relationship between dental anxiety and oral health-related emotional well-being. Int J Paediatr Dent. 2013;23(3):180-187.
    PubMed Google Scholar
11. Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: exploring the interplay between oral health, service utilization, and dental fear. BMC Oral Health. 2007;7:1. doi:10.1186/1472-6831-7-1
    Article PubMed Google Scholar
12. Oral T, Ersan C. Çocuklarda 8-11 yaş algılanan stres ölçeğinin Türkçe’ye uyarlama çalışması [Adaptation of the perceived stress scale in children 8-11 years old to Turkish]. 2017;(37):419-428. doi:10.21497/sefad.328629
    Article PubMed Google Scholar
13. Davis C, Turner-Cobb JM. The Perceived Stress Scale for Kids, PeSSKi: initial development of a brief measure for children aged 7-11 years. Stress Health. 2023;39(1):125-136. doi:10.1002/smi.3174
    Article PubMed Google Scholar
14. Khanduri N, Singhal N, Mitra M. The prevalence of dental anxiety and fear among 4- to 13-year-old Nepalese children. J Indian Soc Pedod Prev Dent. 2019;37(4):345-349. doi:10.4103/jisppd.jisppd_108_19
    Article PubMed Google Scholar
15. Seydaoglu G, Dogan M, Uguz S, Inanc B, Diler R. Reliability and validity of the Turkish version of “dental subscale of the children’s fear survey schedule” and the frequency and risk factors of dental fear in children. J Ege Univ Fac Dent. 2006;27:31-38.
    PubMed Google Scholar
16. Leung DYP, Lam TH, Chan SSC. Three versions of Perceived Stress Scale: validation in a sample of Chinese cardiac patients who smoke. BMC Public Health. 2010;10:513. doi:10.1186/1471-2458-10-513
    Article PubMed Google Scholar
17. Arslan I. Bilinçli farkındalık, depresyon ve algılanan stres arasındaki ilişki [The relationship between mindfulness, depression, and perceived stress]. Kitap ve Bilim. 2018;16:73-86.
    PubMed Google Scholar
18. Alvesalo I, Murtomaa H, Milgrom P, Honkanen A, Karjalainen M, Tay KM. The Dental Fear Survey Schedule: a study with Finnish children. Int J Paediatr Dent. 1993;3(4):193-198. doi:10.1111/j.1365-263x.1993.tb00083.x
    Article PubMed Google Scholar
19. Kleiman M. Fear of dentists as an inhibiting factor in children’s use of dental services. J Dent Child. 1982;49:209-213.
    PubMed Google Scholar
20. Peretz B, Nazarian Y, Bimstein E. Dental anxiety in a students’ paediatric dental clinic: children, parents, and students. Int J Paediatr Dent. 2004;14(3):192-198. doi:10.1111/j.1365-263x.2004.00545.x
    Article PubMed Google Scholar
21. White BP. The perceived stress scale for children: a pilot study in a sample of 153 children. Int J Pediatr Child Health. 2014;2(2):45-52. doi:10.12974/2311-8687.2014.02.02.4
    Article PubMed Google Scholar
22. Yildirim TT, Dundar S, Bozoglan A, et al. Is there a relation between dental anxiety, fear, and general psychological status? PeerJ. 2017;5.
    PubMed Google Scholar
23. Yahyaoğlu Ö, Baygın Ö, Yahyaoğlu G, Tüzüner T. 6-12 yaş grubu çocuklarda diş hekiminin diş görünüşünün dental durum ile ilişkisinin değerlendirilmesi [Evaluation of the effect of dentists’ appearance related with dental status in 6-12 years old children]. Ataturk Univ Dis Hek Fak Derg. 2018;28(3):292-304.
    PubMed Google Scholar
24. Beena J. Dental subscale of children’s fear survey schedule and dental caries prevalence. Eur J Dent. 2013;7(2):181-185.
    PubMed Google Scholar
25. Doğaner YÇ, Aydoğan U, Yeşil HÜ, Sarı O, Koç B. Genç bireylerde dental anksiyete ve ilişkili faktörler [Dental anxiety and related factors in young individuals]. Gulhane Tip Derg. 2015;57(2):160-164.
    PubMed Google Scholar

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About This Article

Received:

July 2, 2024

Accepted:

September 12, 2024

Published Online:

August 26, 2024

Printed:

September 1, 2024