Evaluation of Dental Anxiety in Parents Accompanying their Children for Dental Treatment

Dental anxiety, a state of unpleasantness with associated fear of danger from within or a learned process of one’s own environment is a common hindrance in the dental treatment. The anxiety associated with the dental situation is a concern for the dentist as it leads to avoidance of dental treatment. Approximately 6 to 15% people worldwide suffer from high dental fear.1 Dental anxiety has multifactorial origin with the major causes being illiteracy, lack of dental awareness, irregular dental attendance, maternal anxiety and socioeconomic status. A traumatic past dental experience and attitude of dentist were found to be fear provoking factors in dental anxiety.2,3


INTRODUCTION
Dental anxiety, a state of unpleasantness with associated fear of danger from within or a learned process of one's own environment is a common hindrance in the dental treatment. The anxiety associated with the dental situation is a concern for the dentist as it leads to avoidance of dental treatment. Approximately 6 to 15% people worldwide suffer from high dental fear. 1 Dental anxiety has multifactorial origin with the major causes being illiteracy, lack of dental awareness, irregular dental attendance, maternal anxiety and socioeconomic status. A traumatic past dental experience and attitude of dentist were found to be fear provoking factors in dental anxiety. 2,3 The onset of dental anxiety occurs in childhood, peaks in early adulthood and declines with age. 2 Dental anxiety of childhood and adolescence may persist leading to development of disruptive behavior. 4 Dental anxiety causes frequent and serious problems for the dentist as well as the patients leading to harmful effects like avoidance and cancellations of dental appointments as well as unacceptable behavior during the procedure like crying, anger. 3 Anxiety in a child develops with the existence of anxious people around them. Dental behavior of children is under the influence of the parent's attitude and parents with high level of anxiety exert a negative influence on their children. While discussing the role of family's influence on children, Lechner 5 considered maternal anxiety as the primary factor influencing child behavior. 6 The literature is replete with articles discussing the influence of maternal anxiety on children but only few studies have been conducted on father's anxiety.
Corah's Dental Anxiety Scale is one of the most widely used and studied instrument for measuring dental anxiety. Corah's DAS has been modified by the addition of a fifth item that asks about responses to administration of local anesthetic. The modified scale has high levels of reliability and validity. The scale yields a score of 4 to 20, with scores greater than 15 are indicative of phobic levels of anxiety. 1, [7][8][9] The purpose of the present study was to evaluate the anxiety level of parents accompanying children for their dental treatment. Sample selection: A total of 101 subjects including 58 female and 48 male parents accompanying their children to the dentist, willing to participate in the study were selected. Only parents well versed in Nepalese language were included in the study.The samples were asked to complete the questionnaire in the waiting area.

MATERIALS AND METHODS
Questionnaire: Questionnaire used was the translated Nepalese version of Dental Anxiety Scale-Revised (DAS-R) which was validated prior to the study. The questionnaire consisted of 5 close ended questions relating to various dental situations and each question had 5 options. After the informed consent was obtained the parents completed the questionnaire in the dental operatory. Confidentiality was maintained. Statistical analysis was carried out using SPSS version 17.

RESULTS
In the present study anxiety levels of 101 parents accompanying their children aged 20 to 53 years were analyzed. Among the subjects 44.6% were between 20 to 31 years and 55.4 %were 32 years and more (Table  1).
The present study showed that 62.4% parents accompanying their children had no or low anxiety level with only 9.9% and 5.9% showing high to severe anxiety respectively. 21.8% parents showed moderate anxiety levels ( Figure 1).  Among the studied sample, 26.7 % males and 35.6 % females showed low anxiety level and equal percentage of males and females showed severe anxiety levels (2.9%). 8.9% females showed high anxiety while only 0.9% males were highly anxious. The finding was not statistically significant (p-value 0.941) ( Figure 2).
There was no statistical significant difference between the two age groups of the parental age; 29.7 % of sample less than 32 years and 32.7% sample more than 32 years showed moderate to severe anxiety (p-value -0.425) ( Table  2).  The present study based on Dental Anxiety Scale-Revised (DAS-R) questionnaire (Table 3) showed that, 71.3 % of the respondents would look forward to go to the dentist as an enjoyable experience and only 10.9% would be very frightened of what the dentist does.
According to questionare, 64.4% of the participants would feel little uneasy waiting for their turn in the chair, 21.8% would feel relaxed, while the rest would show higher anxiety levels.
While waiting for the dentist to get the drill ready to start working 57.4% would feel a little uneasy, 16.8 % would feel relaxed, 9.9% of the participants would be anxious and so anxious that would break out into sweat.
While waiting for the instruments to be ready, 54.5 % would feel a little anxious. 21.8 % would be relaxed while 11.9% would be anxious.

DISCUSSION
The present study assessed the dental anxiety level of parents using the validated Nepalese version of Dental Anxiety Scale-Revised (DAS-R). DAS scale is the most widely used measure of dental anxiety and was developed to measure psychological stress. 7 The Corah Dental Anxiety Scale (DAS) was introduced in 1969 as a brief, valid, and reliable instrument to measure anxiety about dental visits. In 1994, the DAS was revised by Ronis et al 10 as the Dental Anxiety Scale-Revised (DAS-R) to acknowledge the role of dental hygienists and female dentists in the dental office.1The scale consists of four questions related to the dental situations with the first two questions relating to anxiety generally and the latter two relating to anticipated fear of specific stimuli. 1, 7-9 Dental anxiety is seen in approximately (6-15%) of the population and is a learned process of unpleasantness to one's own environment. 1, 11 Similar finding was noted in the present study where 16.8 % of the subjects showed high to severe fear.
Dental anxiety has multifactorial origin, and among the environmental factors parental dental fear is strongly correlated to that of the child. 12 Markus et al 13 in a meta-analysis demonstrated a significant relationship between parental and child dental anxiety. Parental anxiety has perhaps received the most attention within the literature as an important external factor that may influence the child's anxiety and behavior within the dental setting. 12,14,15 In the present study 37.6% parents accompanying their child for dental treatment showed moderate to severe anxiety levels.
Mothers with high levels of dental anxiety exerting negative influence on their children have been depicted by Lechner 5 and Ripa. 16 Folyani et al 17 reported significantly high level of dental anxiety among mothers as compared to fathers. Similar finding was reported in a study conducted in Israel by Benjamin and Dan 6 that mothers had higher anxiety level as compared to their husbands. Literature is replete with articles suggesting the influence of maternal anxiety in child behavior. 2,5,6,16,17,18 The influence of dental anxiety of father has been largely ignored. Although many authors have reported that dental anxiety is more common in women than in men. 2,17 There was no statistically significant difference in the anxiety levels of fathers and mothers in the present study which is in agreement to the findings of Sari et al 19 and Ersin and Seniz. 20 Parents' perception of dental appointments being unpleasant may be passed onto children. An assessment of parents fear prior to child's dental treatment may help the clinician in modifying behavior management strategies. Whenever parental anxiety is high, efforts to reduce the parents' level of anxiety may also benefit the child. Providing parents with information about their child's dental treatment has been found to be an effective intervention in reducing the pre-operative anxiety of the parents. 14, 21

OJN
Parents are generally seen accompanying their children to the Pediatric dentist and to the Orthodontist. Dental anxiety is therefore not only encountered in parents visiting Pediatric dentist but is common in the Orthodontic clinic as well. Studies have reported high anxiety levels in parents of children awaiting orthodontic treatment which could affect the outcome of their child's treatment. 19.20 Good dental health education, regular dental visits, good patient-dentist relationship, and effective communication with patients and parents may all contribute to the control of dental anxiety. This study addressed only on parental dental anxiety, the correlation of parent's anxiety and its influence on children remains to be investigated.

CONCLUSION
It can be concluded from the present study that 37.6 % parents accompanying their children showed moderate to severe anxiety levels. There was no significant difference seen in the anxiety levels between the two age groups. The anxiety levels of mothers and fathers were not significantly different. The dental anxiety levels in parents may influence the anxiety levels of children. Therefore identifying anxiety levels of parents accompanying their children can help the clinician in designing the behavior management strategies for the child accordingly.