Dental Anxiety in Children with Cleft Lip and Palate: A Pilot Study Muharrem Cem Dogana/Buse Ayse Serinb/Aslıhan Uzelc/Gulsah Seydaoglud Purpose: To investigate the level of dental fear and anxiety of children who have cleft lip and palate (CLP). Materials and Methods: The study was performed at Cukurova University, Faculty of Dentistry. A total of 32 7- to 12-yearold children, 17 of them with CLP (8 girls and 9 boys) and 15 of them without CLP (7 girls and 8 boys) participated in the study. The children were evaluated by using the Facial Image Scale (FIS) and Dental Subscale of Children’s Fear Survey Schedule (CFSS-DS) methods. The anxiety state of the children was assessed twice using FIS: first in the dental hospital waiting room (FIS-WR) and after, while sitting in the dental chair (FIS-DC). CFSS-DS was administered to all participants in order to assess the dental anxiety while they were sitting in the dental chair. Results: According to the FIS results, there was no difference between CLP and control group in the waiting room (P = 0.682). However, the CLP group showed lower scores than the control group while they were sitting in the dental chair (P = 0.030). The FIS scores of the CLP group were significantly higher in the waiting room than while sitting in the dental chair (P = 0.007). In the control group, there was no significant difference between FIS-WR and FIS-DC values (P = 0.664). The total CFSS-DS scores of children with CLP were lower than those of the control group, but these differences were not statistically significant (P > 0.05). Conclusion: Children with CLP showed more anxiety in the FIS-WR than in the FIS-DC, but they showed lower scores than the control group in the FIS-DC. The positive previous experience of meetings with dentists of the CLP children could explain these results. Positive previous experiences with dentists and a short time in the waiting room could be key elements in the care of CLP children. Key words: CFSS-DS, children, CLP, dental anxiety, FIS Oral Health Prev Dent 2013;11:141-146 doi: 10.3290/j.ohpd.a29364
In children, dental anxiety and fear of dental treatment have been recognised as a source of problems in management for many years (Klingberg, 1995). Children’s dental anxiety is a distressing problem for dentists, parents and children themselves. It is therefore imperative that dentists assess dental anxiety in their young patients as early
Associate Professor, Department of Paediatric Dentistry, Faculty of Dentistry, University of Cukurova, Adana, Turkey.
Dentist, Department of Paediatric Dentistry, Faculty of Dentistry, University of Cukurova, Adana, Turkey.
Assistant Professor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey.
Associate Professor, Department of Biostatistics, Faculty of Medicine, University of Cukurova, Adana, Turkey.
Correspondence: Dr. Buse Ayse Serin, Department of Paediatric Dentistry, Faculty of Dentistry, University of Cukurova, Adana, Turkey 01330. Tel:+90-322-338-6354, Fax:+90-322-338-7331. Email: [email protected]
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Submitted for publication: 11.11.11; accepted for publication: 22.05.12
as possible in order to identify those who are in special need with regards to their fear (Cuthbert and Melamed, 1982). Age, gender and socioeconomic status play important roles as determining factors in dental anxiety (Holst et al, 1987; Klingberg et al, 1994; Dogan et al, 2006); of these, age is the best-known factor for dental anxiety (Cuthbert and Melamed, 1982; Klingberg et al, 1994; Ten Berge et al, 2002). However, the relationship between dental anxiety and age becomes less important as the child reaches 6 or 7 years of age or older, because the child can cope better with potentially anxiety-provoking experiences after this age (Corkey and Freeman, 1994; Folayan et al, 2003). Another aetiological factor of dental anxiety is gender. Gender may not predict dental anxiety by itself, but interaction with the other variables could predispose children to the problem (Corkey and Freeman, 1994; Klingberg, 1995; Dogan et al, 2006). Some clinical studies reported
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Fig 1 Facial image scale with image scores, 1–5.
that there is a strong relationship between high levels of dental anxiety and low socioeconomic status, whereas others have come to the opposite conclusion (Klingberg, 1995; Folayan et al, 2003). Cleft lip and/or palate (CLP) is one of the most common birth defects (Christensen and Mortensen, 2002). Children with CLP require extensive interdisciplinary care throughout their early life, involving plastic surgery, maxillofacial or craniofacial surgery, dentistry (paediatric, orthodontic and oral surgical care, etc), ear, nose and throat surgery, audiology, speech- and psychotherapy. For these patients, the intact dental occlusion and healthy teeth establish the basis for future orthodontic therapy. Routine oral hygiene and prevention of dental caries are therefore very important. Since the paediatric dentist faces CLP children from very early childhood, he/she is the responsible person who follows the patient, organises the dental treatment plan and is usually responsible for assessing the dental anxiety status of these children. There are only a few studies about the dental anxiety of CLP children CLP in the dental literature. A recently published study on this topic found that CLP children aged between 4 and 6 years had experienced more dental fear than children without CLP (Vogels et al, 2011). Thus, the aim of this study was to evaluate the dental fear and anxiety of CLP children and to compare it with children without CLP.
MATERIALS AND METHODS This study was conducted at the Paediatric Dentistry Department of Cukurova University, Adana, Turkey, over a 3-month period. After the study was explained to parents, they signed informed consent forms. The study was approved by the Ethics Committee of Cukurova University. A total of 32 7- to 12-year-old children, 17 of them with CLP (8 girls and 9 boys) and 15 of them without CLP (7 girls and 8 boys) participated in the study. The CLP children included in this study were referred from the Orthodontics Clinic to the Paediatric Dentistry Clinic at the Faculty of Dentistry, University of Cukurova, for their dental treatment. The mean number of vis-
its was 5.6 (min: 2; max: 12). The control group was chosen from patients admitted for the first time to our clinic for their dental treatment without any congenital malformations or medical problem. Seven children were excluded from the study because of unwillingness of parents to answer questionnaires. The dental anxiety of CLP children was compared with the control group by using FIS and CFSS-DS. The Facial Image Scale (FIS) uses faces as an indicator of anxiety and is one of the simplest and most suitable measures for assessing children’s dental anxiety, while giving immediate feedback on the child’s state to the clinician (Buchanan and Niven, 2002). FIS comprises a row of five faces ranging from very happy to unhappy (Fig 1). The scale is scored by giving a value of one to the most positive face and five to the most negative. The FIS was applied twice and the children were asked to point to which face that they felt most like at that specific moment, first in the dental hospital waiting room (FIS-WR) and later while they were sitting in the dental chair (FIS-DC). Subsequently, the CFSS-DS (Dental Subscale of Children’s Fear Survey Schedule) was also administered to all participants in order to assess the dental anxiety and fear, as well as general anxiety, while they were sitting in the dental chair. The children filled out questions by themselves and were helped, if needed, by the same dental assistant for each child. The CFSS-DS consists of 15 questions, rated from 1 = ‘not afraid at all’ to 5 = ‘very afraid’. Scores for all 15 items were summed to obtain the total dental anxiety score. A total CFSS-DS score greater than 38 was considered as high anxiety (Klingberg et al, 1994). The reliability and validity of the Turkish version of CFSS-DS was performed in a previous study (Dogan et al, 2006). According to the results of factor analyses of this study, three factors were calculated for CFSS-DS in order to define the source of the fear in detail. Factor 1 related to highly invasive dental procedures and asks 5 questions about dentists, injections, the dentist drilling, the sight of the dentist’s drill and the noise of the dentist’s drill. Factor 2 related to less invasive dental treatment and asks 7 questions about
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Table 1 Reliability of CFSS-DS Factors
1.Highly invasive dental procedures
2. Less invasive dental treatment
3. General anxiety
The dentist’s drill
The sight of dentist’s drill
The noise of dentist drilling
Having somebody examine your mouth
Having to open your mouth
Having somebody put instruments in your mouth
Having to go to the hospital
People in white uniforms
Having the nurse clean your teeth
Having somebody look at you
Having a stranger touch you
doctors, having somebody examine your mouth, having to open your mouth, having somebody put instruments in your mouth, having to go to the hospital, people in white uniforms and having the nurse clean your teeth. In addition, factor 3 related to general anxiety and asks 3 questions about having a stranger touch you, having somebody look at you and fear of choking.
Statistical analysis Statistical analyses were performed using the statistical package SPSS version 15.0 (Chicago, IL, USA). For each continuous variable, normality was checked with the Shapiro Wilks test. Since the data were not distributed normally, the Mann-Whitney Utest was applied for comparisons. For intragroup comparisons which were not distributed normally, the Wilcoxon signed rank test was used. To compare the qualitative data, the chi-square test was used. To test the reliability, Cronbach’s alpha was calculated. Results were presented as mean, standard deviation, median, min-max, frequency
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and percentage. A P-value 0.05). The mean score of fear of highly invasive dental procedures was significantly higher in the control than the CLP group (P = 0.006). There was a high correlation between FIS-WR and FIS-DC (r = 0.71) and between FIS-DC and CFSS-DS (r = 0.69).
DISCUSSION In this pilot study, we tested the hypothesis that there was a difference between the dental anxiety of children with and without CLP. The dental anxiety of CLP children was compared with the control
group by using CFSS-DS and FIS. CFSS-DS, developed by Cuthbert and Melamed (1982), is a valid and reliable tool for measuring dental anxiety in children. The Facial Image Scale (FIS) is a simple and suitable measure for assessing children’s dental anxiety, and is quick and easy to administer in the dental waiting room. It took less than 1 minute to conduct. FIS gives immediate feedback to the clinician on the children’s state in the waiting room and dental chair. The FIS scores of CLP children while sitting in the dental chair (FIS-DC) were lower than the control group, but they had more dental anxiety in the waiting room (FIS-WR) than in the dental chair. The CLP children had lower dental anxiety than the children without CLP both in the dental chair and in the waiting room. The decrease in anxiety from the waiting room to the dental chair can be explained by anticipatory anxiety, which is often worse than the real moment of coping with the stimulus. On the other hand, it is also possible that CLP children experienced less anxiety in the dental chair than did the children in the control group because they had positive previous experience of meetings with dentists and they knew what to expect. Previous studies have reported a relationship between children’s dental fear and the treatment pro-
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cedures they had experienced (Ten Berge et al, 2002; Karjalainen et al, 2003). Dental fear was less often reported for children who had experience of orthodontic treatment, and was most often reported by children who had experience of fillings. Children without any experience of treatment reported dental fear more often than children with experience of orthodontics (Luoto et al, 2009). Orthodontic treatment is less invasive and painful. These positive experiences may thus prevent dental fear and increase the child’s coping abilities and feeling of control in dental situations, even when more invasive treatment is needed in the future. When CFSS-DS scores were analysed, the scores of CLP children in the area of highly-invasive dental treatment were lower than the control group. Among children of this age (7–12 years), fear of treatment procedures has been shown to be more common than other aspects of dental fear (Rantavuori et al, 2005), probably due to the fact that they have been exposed to more treatment procedures associated with dental fear (Ten Berge et al, 2002, Karjalainen et al, 2003). Moreover, result of the questionnaire showed that they disliked having somebody look at them or having a stranger touch them. A number of literature reviews have been conducted describing the psychological status of individuals with CLP (Richman and Eliason, 1982; Eliason, 1991; Tobiasen and Hiebert, 1993; Hunt et al, 2005; Alanko et al, 2010). Overall, these reviews conclude that such children do not suffer from any significant psychopathology. However, in all of the reviews, it is reported that CLP children can demonstrate more cognitive, behavioural and emotional difficulties. Dissatisfaction with facial appearance, social isolation, speech difficulties and poor selfimage may be identified as the source (Hunt et al, 2005). According to the results of this study, CLP children have lower dental fear in the dental chair than do children without CLP. This finding supports the idea that children’s dental anxiety may decrease with regular exposure to medical intervention. CLP children have higher dental fear in the waiting room than sitting in the dental chair. This result indicates that fear and anxiety may be elevated in these children in public situations. The subscales of the CFSS were evaluated in order to understand the source of fear and anxiety. While the factors related to the dental procedures were significantly lower in CLP children (perhaps related to the greater number of visits), the level of general anxiety was as high as in children without CLP. Although the num-
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ber of items included in CFSS about the general anxiety is limited (only 3 items), these scores can be used as prior information. This study indicates that the anxiety level of CLP children may be related to general anxiety. Further studies should include the measures of trait and state anxiety levels besides the dental anxiety level, and the clinical judgment of a psychiatrist must be obtained.
CONCLUSION Special behavioural management techniques can be developed for CLP children. For instance, they should not have to wait for a long time in the waiting room and the dentist should determine the general anxiety levels. Further studies might investigate the psychological status of CLP children in a larger sample size by working together with a specialist in child psychology and complete these comparisons for sex, age and socioeconomic status.
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