Received: 13 May 2016 | Accepted: 16 January 2017

DOI: 10.1111/cdoe.12290

ORIGINAL ARTICLE

Development of dental anxiety in schoolchildren: A 2-year

prospective study

Fernanda C. Soares1,2 | Rodrigo A. Lima3,4 | Mauro V. G. de Barros5 |

€ ran Dahllo
Go € f2 | Viviane Colares1

1
Division of Pediatric Dentistry,
Department of Pediatric Dentistry, Abstract
University of Pernambuco, Recife, Brazil Aim: To assess the development of high dental anxiety and the factors that are
2
Division of Pediatric Dentistry,
associated with it over a 2-year period.
Department of Dental Medicine, Karolinska
Institutet, Stockholm, Sweden Design: This longitudinal study focused on 416 Brazilian children aged 5-7 years
3
Center for Research in Childhood Health, over 2 years. Interviews were conducted with the children’s parents to investigate
University of Southern Denmark, Odense,
Denmark the children’s health-related behaviours. Additionally, the children’s dental caries
4
CAPES Foundation, Ministry of Education experience was clinically evaluated to obtain information about DMFT/dmft
of Brazil, Brasilia, Brazil
(decayed, filled and missing teeth) indices. Using the Dental Anxiety Question,
5
School of Physical Education, University of
Pernambuco, Recife, PE, Brazil
children whose parents responded “yes” to the prompt “Is he/she very afraid of
going to the dentist?” were classified as having high dental anxiety. Multilevel
Correspondence
Fernanda C. Soares, Universidade de
mixed-effects logistic regression was used to analyse factors to determine the
Pernambuco - Reitoria/UPE, Avenida extent to which they were associated with high dental anxiety longitudinally.
Agamenon Magalh~aes, Santo Amaro, Recife,
PE, Brazil
Results: The prevalence of high dental anxiety in children at baseline was 16.2%,
Email: [email protected] whereas it was 19.8% at follow-up. Additionally, 38% of the children with high den-
tal anxiety at baseline still had the condition after two years, although 62% of them
no longer had high dental anxiety. The incidence of high dental anxiety at 2-year
follow-up was 15.0%. Children who used medication chronically had a 2.1 times
greater likelihood of having high dental anxiety. Furthermore, children whose par-
ents reported high dental anxiety had a 2.6 times greater likelihood of having high
dental anxiety themselves. A one-unit increase in a child’s dmft score increased the
risk of high dental anxiety by 1.1 times at follow-up.
Conclusion: After two years, the incidence of high dental anxiety was 15.0%. Poor
oral health, unstable general health and parents with high dental anxiety were
factors that were associated with this type of anxiety in schoolchildren. It is
important that dentists are aware of children’s high dental anxiety and the associ-
ated factors so that they can appropriately intervene. Dentists fulfil an important
role and should stimulate and promote good general hygiene habits that may
prevent future problems.

KEYWORDS
Child, Dental anxiety, Cohort Studies

Community Dent Oral Epidemiol. 2017;1–8 wileyonlinelibrary.com/journal/cdoe © 2017 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 | SOARES ET AL.

1 | INTRODUCTION children.13 High dental anxiety has also been found to be associated
with parental smoking.14
Members of the general population commonly perceive the dentist Studies that have evaluated high dental anxiety have been per-
negatively, feeling scared or threatened. Thus, dental anxiety in chil- formed in dental offices. Thus, children were not in a neutral environ-
dren is prevalent,1 especially in developing countries such as Brazil1 ment, and their responses may have been influenced by the dental
and Iran,2 with rates reaching 14% and 29%, respectively. Impor- office, which can be seen as a hostile environment. The nonrepresenta-
tantly, it seems that the dental anxiety prevalence does not tend to tiveness of the samples is also a concern in relation to previous studies.
3
decrease with increasing age. Dental anxiety can start in childhood Children with high dental anxiety do not or seldom go to dentists; there-
and remain a complex and multifactorial phenomenon throughout fore, they are underrepresented when children who go to dental clinics
life.4 It can be caused by traumatic events, fear of the unknown, are evaluated. Regarding the factors that are longitudinally associated
socialization processes or even learning/imitating family members with high dental anxiety, studies have examined only factors that are
4
vicariously. Patients with high dental anxiety usually delay their chil- related to oral health. It is necessary to evaluate potentially important
dren’s dentist appointments, which consequently leads to a higher intrinsic and environmental factors that have not been previously exam-
risk of carious teeth,5 which represents a barrier to children’s oral ined. The aim of this study was to investigate the change over 2 years in
health care and a serious challenge for dentists.6 For children, anxi- high dental anxiety among 5- to 7-year-old Brazilian children and the
ety is an unpleasant and uncertain feeling that is difficult to describe factors that are longitudinally associated with such development.
or even identify. Many children have difficulty naming and measuring
such feelings. In particular, the multidimensionality of anxiety makes
2 | MATERIALS AND METHODS
it difficult to measure.
One of the few studies on this topic assessed changes in high
2.1 | Participants
dental anxiety over time and examined the relationship between
anxiety and dental care in a prospective cohort study of 5- to This study is part of a project designed to assess the longitudinal
9-year-old children in the north-western part of England.7 The pro- changes in health, physical activity practices, anthropometric parame-
portion of children who developed anxiety was 11.7%. The odds of ters, motor skill performance and other lifestyle factors in preschool
children’s having high dental anxiety are higher in girls, children children (Longitudinal Study of Health and Well-Being in Preschool
whose parents have high dental anxiety and children with a history Children—ELOS—Pre Project). This project started in 2010. Data
of extraction and irregular dental visits.3 In a Finnish study, Luoto have been collected every other year in preschools in Recife, Per-
et al. observed the longitudinal changes in high dental anxiety in nambuco State, Brazil. An oral health evaluation was included in the
children aged 11 and 12 years and their parents separately. They initial follow-up at ages 7 and 9 years in 2012. Thus, for this study,
conducted two follow-up studies over a 4-year period. Overall, the the data collected in 2012 were considered to be the baseline data.
prevalence of high dental anxiety increased. Girls had more high The protocol was approved by the Human Research Ethics
dental anxiety than boys at the beginning of the study, and this dif- Committee of the University of Pernambuco (protocol no.
ference became more evident at follow-up. However, 24% and 56% 0096.0.097.000-10), and the children’s parents or guardians and
of mothers and children with high dental anxiety at baseline, respec- school principal provided written informed consent.
tively,8 reported no fear at follow-up. In this study, public and private preschools that were proportion-
Tracking is the persistence of a behaviour or characteristic over ate in size (number of children) and location in the six political
time9 or the tendency of an individual to maintain his or her posi- administrative regions of the city were selected. All children aged 3
tion in a group when evaluated longitudinally.10 Evaluating the to 5 years were invited to participate in the study, and the parents
tracking characteristics of a health-related behaviour is important to of 1155 children agreed to participate. In 2012, the follow-up rate
determine whether it is possible to improve a particular characteris- was 76% (n=784; mean age=6.00.7). Furthermore, 416 (53%; mean
tic to prevent subsequent undesirable outcomes. Few studies have age=8.00.7) of 781 children examined at baseline returned for fol-
reported the tracking of high dental anxiety during childhood to low-up in 2014 (Figure 1).
understand its direct or indirect negative effects on children’s
health.
2.2 | Measures
In addition to evaluating the maintenance of high dental anxiety
in children, it is essential to identify its causative factors. This is We conducted face-to-face interviews with the children’s parents to
important for reducing the possible negative health consequences of obtain information on their socioeconomic status and health beha-
high dental anxiety. Although oral health,11,12 family income1 and viours. Information was collected on gender (male, female), childbirth
parents’ high dental anxiety1,6,11 were found to be associated with (normal, caesarean), parentage (natural parents, adoptive parents),
high dental anxiety in cross-sectional studies, it is possible that other family income (≤2 minimum wages, >2 minimum wages—Brazilian
factors also are associated with it. The current study showed that minimum wage was 240 USD at data collection), maternal education
high dental anxiety was associated with sex, caesarean childbirth, level (≤8 years of education, >8 years of education), parental smok-
psychological well-being, physical well-being and number of ing (no, yes), number of children in the family (≤2 children, >2
SOARES ET AL. | 3

F I G U R E 1 Flow chart of the

longitudinal follow-up of study participants

children), breastfeeding (≤6 months, >6 months) and parental marital spatulas, and procedures were performed under artificial light. Each
status (lives with partner, lives alone). tooth was assessed for caries, restorations and extractions. A tooth
The general health variables used were lack of energy to perform was classified as carious if on a smooth surface there was visual evi-
exercise (yes, no), physical problems (yes, no), emotional problems dence of cavitation (ie a break in the enamel surface) or if on the occlu-
(yes, no), chronic use of medication (ie continuous use for at least sal surface there was evidence of cavitation or undermined enamel,
6 months) (yes, no), hospitalization (yes, no), childhood obesity (yes, including frosting or shadowing of the enamel. White spots and
no) and parental obesity (yes, no). nonocclusal precavitated lesions were not assessed. For each child,
Children were weighed while wearing light clothing with no the number of decayed (d) teeth indicated for extraction (m), filled (f)
shoes on a Filizola scale to the nearest 0.1 kg. Their height was mea- primary teeth and decayed (D), missing (M) and filled (F) permanent
sured to the nearest 0.5 cm using a wall-mounted stadiometer teeth was determined. These numbers were summed to create dmft
â
(Welmy , S~ao Paulo, Brazil). Their body mass index (BMI) was calcu- and DMFT measures.16
2
lated by dividing the body weight by the height squared (kg/m ) for The Dental Anxiety Question (DAQ)17 was used to assess the
15
their children’s respective sex and age. Parental BMI was calcu- dental anxiety of children and parents. To evaluate the child’s pho-
lated using their self-reported height and weight (weight/height2). bia, the following question was asked to the parents: “Is your child
The following oral health information was collected: frequency of afraid of going to the dentist?” This question had four possible
tooth brushing (one or no times a day, more than one time a day), visits answers: “No,” “Yes, somewhat,” “Yes, he/she is afraid” and “Yes,
to dentists in the last year (no, yes) and dental trauma (no, yes). Oral he/she is really afraid”. To evaluate the parent’s phobia, they were
examination in each child was conducted using disposable wooden asked a similar question: “Are you afraid of going to the dentist?”
4 | SOARES ET AL.

This question also had four potential answers: “No,” “Yes, some- observed. The kappa test evaluated the stability (tracking) of high
what,” “Yes, I am afraid” and “Yes, I am really afraid.” Based on the dental anxiety in the children over time.
response to this question, two groups were formed. The children of The proposed model to evaluate dental anxiety and its associ-
parents who answered “No”, “Yes, somewhat” and “Yes, he/she is ated factors was based on the models relating to general anxiety
afraid” were categorized as having no/low dental anxiety, whereas the presented in Brown et al.18 and Spielberger.19 In addition, the
children of parents who answered “Yes, he/she is really afraid” were model was partially based on already known DA-associated factors.
categorized as having high dental anxiety. The same categorization It also included other factors that the research team thought were
was used for dental anxiety in both the children and their parents. appropriate. Thus, the model was partially theoretical and partially
empirically derived. Multilevel mixed-effects logistic regressions
were used to analyse which factors were longitudinally associated
2.3 | Statistical analyses
with high dental anxiety. First, several analyses were performed
All statistical analyses were conducted in STATA 13 for Windows (crude model) to examine the factors that were associated with
(StataCorp LP, College Station, TX, USA). Chi-square or t-tests high dental anxiety, and then, all the variables with a P-value <.20
were used to examine the statistical significance of the differences in the adjusted model were tested. All the final models were

T A B L E 1 Social and behavioural characteristics of the participants at baseline (2012) and follow-up (2014) as well as dropouts
2012 2014 Drop-outs
(n=781) (n=416) (n=365) P-value
Child characteristics
Age, mean (SD) 6.4 (0.8) 8.4 (0.8)

n % n % n %
Gender, male 406 52 222 53 184 45 <.001a
Child birth, Caesarean 350 46 187 47 163 47 <.001a
Parentage, nature 682 87 368 89 314 46 <.001a
Socioeconomic status
Family income, ≤2 532 69 284 69 248 47 <.001a
Mother education, ≤8 years 297 39 168 41 129 43 <.001a
Smoke, Yes 105 14 59 14 46 44 <.001a
Number of children, ≤2 503 65 250 60 253 50 <.001a
Exclusively breastfed, <6 months 581 75 302 76 279 48 <.001a
Marital status, living with partner 534 70 268 66 266 50 <.001a
General health
Lack of energy to perform exercises, yes 172 22 94 23 78 45 <.001a
Physical problems, yes 128 16 62 15 66 52 <.001a
Emotional problems, yes 111 14 47 11 64 58 .002a
Medication use, yes 80 10 34 8 46 58 <.001a
Ever hospitalized, yes 377 48 188 45 189 50 <.001a
Child obesity, yes 103 14 76 17 27 26 <.001a
Parental obesity, yes 113 19 80 27 33 29 <.001a
Oral health
Frequency of tooth brushing, once a day or less 81 10 63 15 18 22 <.001a
Dentist visit (last year), no 246 32 105 27 141 57 <.001a
Dental trauma, yes 299 39 139 34 160 54 <.001a
Parental high dental anxiety, yes 126 16 68 16 58 46 <.001a
Child high dental anxiety, yes 136 16 80 19 56 41 <.001a
Mean DMFT index, mean (SD) 0.1 (0.4) 0.1 (0.4) <0.001b
Mean dmft index, mean (SD) 1.0 (2.1) 0.4 (1.2) <0.001b

a
Chi-squared test.
b
t-test.
dmft index = decayed (d), teeth indicated for extraction (m) and filled (f) primary teeth.
DMFT index = decayed (D), missing (M) and filled (F) permanent teeth were determined.
SOARES ET AL. | 5

adjusted for gender and the mother’s education level. In all the participants whom we could not follow at 2014 (dropouts). The chil-
multilevel regression models, the variance related to the clusters dren at follow-up presented similar characteristics as the children at
(school and classes at school) and the intraclass correlation coeffi- baseline (P<.05); therefore, study dropout did not affect the descrip-
cient (ICC) for each model were calculated to interpret the variation tive characteristics of the sample.
among school classes, classes and individuals.20 In all the regression The prevalence of high dental anxiety in the cohort was 16.2% (66
models, the majority of the variation (ICC) was at the individual children) at baseline and 18.9% (77 children) after 2 years of follow-
level (the conjugated ICCs from the school and classes were always up, and the incidence of high dental anxiety was 15.4% (Table 2). At
below 5%). The results are presented as odds ratios and 95% confi- the beginning of the study, 66 children had high dental anxiety. After
dence intervals. 2 years, 25 of those children still had high dental anxiety. On the
other hand, of the 337 children without high dental anxiety at base-
line, 52 developed the condition.
3 | RESULTS The variables tested in the crude model were included in the
adjusted model. They were childbirth, parental smoking (Table 3),
In Table 1, we present the participants’ characteristics at baseline medication use (Table 4), tooth brushing, dental visit in the previous
(2012) and follow-up (2014) as well as the characteristics of the year, parental dental anxiety and caries experience as represented by
the dmft index (Table 5).
T A B L E 2 Change in high dental anxiety within 6 and 8 years
(mean ages) In relation to general health, chronic medication use was associ-
ated with high dental anxiety. Children who used medication chroni-
High dental
cally had a 2.1 times greater likelihood of having high dental anxiety
Baseline Follow-up anxiety
(6 years) (8 years) n (%) than children who did not use medication, regardless of gender or

Remitted case Yes No 41 (10.2)* socioeconomic status (Table 4). Children whose parents had high

New case No Yes 52 (12.9)*

dental anxiety had a 2.6 times greater likelihood of having high den-
tal anxiety than children whose parents did not. We also found that
Resistant case Yes Yes 25 (6.2)*
dmft predicted high dental anxiety. Depending on which tooth was
Never No No 285 (70.2)*
affected by carries, the odds of becoming dentally anxious increased
*Kappa test: P<.005. by 1.1% (Table 5).

T A B L E 3 Multilevel logistic regression model for the incidence of high dental anxiety
Crude model Adjusted model

Variable OR (IC 95%) P OR (IC 95%) P

Childbirth Normal 1 .046* 1 .078
Caesarean 0.59 (0.35-0.99) 0.67 (0.43-1.04)
Parentage Nature 1 .218 – –
Adoptive 1.44 (0.81-2.55) –
Family income (Brazilian minimum wage) ≤2 1 .474 – –
>2 0.82 (0.48-1.40) –
Parental smoking No 1 .183** 1 .400
Yes 1.47 (0.83-2.60) 1.28 (0.72-2.29)
Number of children (mom) ≤2 1 .296 – –
>2 1.26 (0.81-1.96) –
Exclusively breastfed <6 month 1 .469 – –
>6 month 1.18 (0.76-1.84) –
Marital status Living with partner 1 .928 – –
Living alone 0.98 (0.64-1.50) –
Child obesity No 1 .392 – –
Yes 0.78 (0.45-1.36) –
Parental obesity No 1 .528 – –
Yes 0.84 (0.50-1.43) –

*P<.005.
**P<.20.
Adjusted model–adjusted for gender and mother education.
6 | SOARES ET AL.

4 | DISCUSSION with high dental anxiety. To the best of our knowledge, this is the
first study to investigate the change in high dental anxiety in chil-
This prospective longitudinal study focused on children between the dren in a developing country. The incidence of high dental anxiety
ages of five and seven and seven and nine attending public and pri- was 15%. In addition, chronic medication use, parental high dental
vate schools in Recife, Pernambuco State, Brazil. During the second anxiety and caries experience were longitudinally associated with
childhood period (children from 3 to 6 years of age),21 children’s per- high dental anxiety in childhood.
sonalities develop, and they learn new skills and establish beha- This study has limitations that should be taken into consideration
viours. It is during childhood that these concepts are rooted. At when interpreting the findings. The instrument used to investigate
6 years of age, children face profound social changes such as start- high dental anxiety could have led to response bias, as the informa-
ing school and experiencing social pressure to be accepted by their tion was not collected directly from the children. Instead, it was
peers. That is why high levels of anxiety are observed in children obtained from their parents. However, the children were too young

T A B L E 4 Multilevel logistic regression model for the incidence of high dental anxiety—general health factors
Crude model Adjusted model

Variable OR (IC 95%) P OR (IC 95%) P

Lack of energy to perform exercises No 1 .281 – –
Yes 1.27 (0.82-1.98) –
Physical problems No 1 .301 – –
Yes 1.25 (0.79-2.11) –
Emotional problems No 1 .241 – –
Yes 1.37 (0.81-2.30) –
Diseases No 1 .767 – –
Yes 1.08 (0.63-1.84) –
Medication use No 1 .047* 1 .020*
Yes 1.87 (1.01-3.47) 2.14 (1.13-4.06)
Ever hospitalized No 1 .572 – –
Yes 1.12 (0.76-1.66) –
Body dissatisfaction Yes 1 .394 – –
No 0.82 (0.52-1.29) –

*P<.005.
Adjusted model—adjusted for gender and mother education.

T A B L E 5 Multilevel logistic regression model for the incidence of high dental anxiety–oral health factors
Crude model Adjusted model

Variable OR (IC 95%) P OR (IC 95%) P

Frequency of tooth brushing More than once per day 1 .166** 1 .188
Once a day or less 1.47 (0.85-2.54) 1.52 (0.82-2.82)
Dentist visit (last year) No 1 .195** 1 .224
Yes 0.75 (0.49-1.15) 0.74 (0.47-1.19)
Dental trauma No 1 .572 – –
Yes 0.88 (0.59-1.34) –
Parents dental anxiety No 1 <.001* 1 .001*
Yes 2.51 (1.52-4.15) 2.58 (1.47-4.51)
DMFT Mean (SD) 1.01 (0.66-1.52) .999 – –
dmft Mean (SD) 1.22 (1.10-1.33) <.001* 1.14 (1.01-1.29) .036*

*P<.005.
**P<.20.
Adjusted model–adjusted for gender and mother education.
dmft index = decayed (d), teeth indicated for extraction (m) and filled (f) primary teeth.
DMFT index = decayed (D), missing (M) and filled (F) permanent teeth were determined.
SOARES ET AL. | 7

and did not understand the question; therefore, their answers would them more anxious.25 Through anamnesis, it is necessary to identify
have been invalidated. Measuring dental anxiety in children is a con- such patients who should be given increased attention when con-
siderable challenge for researchers.3 The assessment of dental anxi- ducting treatments such as conversations and appropriate cognitive
ety could have had a limitation, as the instrument used, the DAQ, approach techniques. When this conditioning is insufficient, it is
had only one question. The present study is part of a larger epidemi- often important to collaborate with a psychologist.
ological study in which parents must answer more than 100 ques- Parental anxiety triples the risk of children’s having high dental
tions. Thus, it was unrealistic to use a more extensive instrument to anxiety. Milsom et al. and Lara et al. also reported that levels of den-
assess dental anxiety. However, the DAQ has a strong association tal fear in family members are correlated26,27 with children’s high
with Corah’s Dental Anxiety Scale (CDAS) (Spearman r=.71, dental anxiety. A child’s behaviour is directly influenced by the atti-
P<.001).17 Another point that should be taken into consideration is tudes of his or her parents,28 resulting in an educated and stimulated
the percentage of children who were lost to follow-up (47%), even child or a spoiled and insecure one.26 Children formulate their per-
though this loss might not have led to any apparent bias. There were ceptions according to what they see and hear from their parents,
no significant differences at baseline between the children who contributing to an emotional transfer of dental fear levels between
remained in the study and those who dropped out (Table 1). parents and children.27 Thus, parental anxiety is one of the most
The proportion of children with high dental anxiety increased by important factors in determining high dental anxiety in childhood.3 In
three per cent over 2 years, from 16% at baseline to 19% at follow-up. addition to giving attention to the child, in collaboration with parents
The prevalence of high dental anxiety within the 15% to 20% range is who have high dental anxiety, dentists must develop strategies to
similar to the prevalence of high dental anxiety in Brazilian children1,22 change the parents’ view of them, as their perception highly influ-
and preschool children in England.3 However, it is higher than that found ences the child’s dental anxiety. It is the parents’ responsibility to
in other studies.11,23 This inconsistency may have been observed because portray a good image of dentists to the child, explaining that they
the latter studies occurred in dental offices in which children with high are professionals who help to promote health and that it is not nec-
dental anxiety are underrepresented, as they do not regularly visit them essary to be afraid of the dental office.
for care. Another hypothesis is that social and cultural differences existed Children with a higher dmft score as well as greater number of
across the studies that were conducted in different countries. decayed teeth or teeth indicated for extraction have a greater risk of
The increase in the prevalence of high dental anxiety was due to developing high dental anxiety. Poor dental health increases the like-
a high incidence of dental anxiety in children. The majority (62%) of lihood of dental pain and may result in adverse dental care, including
the children who were anxious at baseline were no longer anxious procedural pain and other negative experiences during dental treat-
after 2 years. This finding has been previously reported, and our ment such as unconditioned stimuli, contributing to higher levels of
findings are comparable to those of Tickle et al., who reported that high dental anxiety in these children.29 In this context, to prevent
54% of children who were anxious at age 5 were no longer anxious future problems, dentists can advise parents on preventive measures
at the age of 9.3 According to Piaget, the cognitive development and relating to oral health in the period before the child’s birth during
learning of a child gradually evolve over time, and the child acquires which time the oral hygiene guidelines of the mother and the unborn
21
more complex skills in a logical sequence. In the period between 5 child are realized.
and 7 years of age, children leave the symbolic or pre-operative This is one of the few longitudinal studies on high dental anxiety in
phase (the fantasy period) and move to the concrete operative per- childhood in the literature. It shows that the majority of children who
iod (in which they are able to explain events),24 which explains the were anxious did not have high dental anxiety after 2 years, although
reduction in high dental anxiety. many children developed high dental anxiety, resulting in a high inci-
On the other hand, the relatively high incidence of high dental dence of anxiety. This study also identified factors that were associ-
anxiety (15%) should be highlighted. It has been reported that chil- ated the development of high dental anxiety over time. Childhood is
dren receive greater exposure to pain as they grow older.8 Accord- the period during which personality is developed as well as when chil-
ingly, children who had unpleasant experiences in association with dren learn new skills and establish their behaviours.30 Around the age
medical treatment in this 2-year period are likely to have high dental of six, children face profound social changes, start school and experi-
anxiety. Generally, attention and the appropriateness of the proce- ence the social responsibility of becoming accepted by their peers.2
dure to the child’s world through an explanation of the steps to be This shows the importance of our study to this population.
performed is sufficient for their cooperation and to prevent fear of In conclusion, 15% of the children developed high dental anxi-
dentists. ety after two years of monitoring. Children with poor oral health,
The findings suggest that the aetiology of high dental anxiety in unstable general health and parents with high dental anxiety were
children is multifactorial. Chronic use of medication (ie 6 months or more likely to have high dental anxiety. Parents should be aware
more) doubled the risk of having high dental anxiety during the two of their importance on children’s dental anxiety and avoid negative
years of follow-up. Wogelius et al. reported that asthma drug use is feedback regarding oral health care and stimulate an enjoyable
associated with high dental anxiety. Children who use many medica- approach during dentist visits. Finally, dentists have to identify
tions tend to become sick periodically, increasing their contact with children at risk of having high dental anxiety and intervene appro-
medical care, injections and other treatments that are likely to make priately. Dentists fulfil an important role and should stimulate and
8 | SOARES ET AL.

promote good general hygiene habits that may prevent future 17. Neverlien P. Assessment of a single-item dental anxiety question.
problems. Acta Odontol Scand. 1990;48:365–369.
18. Brown TA, Chorpita BF, Barlow DH. Structural relationships among
dimensions of the DSM-IV anxiety and mood disorders and dimen-
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