Behaviour Research and Therapy 38 (2000) 31±46

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A clinical study of child dental anxiety

Ellen Townend a, Gisela Dimigen a,*, Diane Fung b
a
Department of Psychology, The University of Glasgow, Adam Smith Building, Glasgow G12 8RT, Scotland, UK
b
Department of Child Dental Health, Glasgow Dental Hospital and School, NHS Trust, 378 Sauchiehall Street,
Glasgow G2 3J7, Scotland, UK
Received 26 October 1998

Abstract

Dental fear in children was studied using Rachman's theory of fear acquisition. Sixty children from
two age groups (7±10 years, 11±14 years) participated in the project. The children were new patients
attending a paediatric consultation clinic for specialised dental treatment. Thirty-one were diagnosed as
being clinically anxious regarding dentistry and 29 were found to be nonanxious. Information regarding
children's past experiences and present level of anxiety was obtained from the examining dentist, the
children and their parents. Mothers were also interviewed and observed to ascertain their own anxieties
and behaviour. The results showed that of Rachman's three pathways to fear, conditioning appeared
largely responsible for the children's development of dental fear. Children's fear was more strongly
associated with subjective experience of pain and trauma than with objective dental pathology. Indirect
learning processes were found to be of only minor importance in this study. # 1999 Elsevier Science
Ltd. All rights reserved.

Keywords: Children; Dental fear; Dental anxiety; Conditioning; Modelling; Information

1. Introduction

Child dental anxiety has been a matter of concern for many years (Steen, 1891), however,
it's aetiology is still not entirely understood. The three-pathway theory of Rachman (1977)
provides an apt framework, from within which to study a child's acquisition of dental anxiety.
Children may develop an anxious response directly (by conditioning) or via more indirect

* Corresponding author. Fax: +44-141-330-5086.

E-mail address: G.Dimigen@psy.gla.ac.uk (G. Dimigen)

0005-7967/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 0 5 - 7 9 6 7 ( 9 8 ) 0 0 2 0 5 - 8
32 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

learning (by modelling or from information). The bulk of child dental fear research has
investigated the conditioning process (Brown, Wright & McMurray; 1986; Murray, Liddell &
Donohue, 1989; Bedi, Sutcli€e, Donnan, Barret & McConnachie, 1992a; Klinberg, Berggren,
Carlsson & NoreÂn, 1995; Milgrom, Mand, King & Weinstein, 1995; Poulton et al., 1997).
However, the modelling and informational pathways have fared less well. The literature
appears to lack a clear understanding of these concepts (Litt, 1996) and there has been a
tendency to ignore them empirically.
The conditioning pathway has generally been supported by adults with dental phobia, who,
tend to attribute their fear to conditioning experiences (Lautch, 1971; Ost & Hugdahl, 1985;
Ost, 1987; Moore, Brodsgaard & Birn, 1991). However, research with children has produced
more mixed results. Findings by Milgrom et al. (1995) do seem to mirror the adult studies,
while Bedi et al. (1992a) and Klinberg et al. (1995) found that conditioning played only a
minor role. Other researchers even report a negative relationship between fear and invasive
treatment, implying that exposure may actually act prophylactically (Brown et al., 1986;
Murray et al., 1989).
The discrepancy between adult and child ®ndings may be explained in light of the di€erent
methods used to investigate conditioning. Researchers have attempted to measure children's
conditioning objectively: by using treatment records (Murray et al., 1989) or pathology indices
(Brown et al., 1986; Bedi et al., 1992a; Klinberg et al., 1995; Milgrom et al., 1995; Poulton et
al., 1997). In contrast, adult conditioning is generally assessed by subjective reports of past
`traumatic' dental experiences.
The level of perceived `trauma' may be mediated by the practising dentist's manner. A
strong relationship between dental fear and negative dentist behaviour has been found in
several studies (Berggren & Meynert, 1984; Moore et al., 1991; Kleinhauz, Eli, Baht &
Shamay, 1992; Eli, Uziel, Baht & Kleinhauz, 1997). For example, Milgrom, Vignehsa and
Weinstein (1992) found that adolescents were nine times more likely to be highly anxious of
dental treatment if they thought that their dentist was unsympathetic.
The conditioning of fear may be further modulated by the timing of potentially unpleasant
events. Timing of `traumatic' events was investigated by Davey (1989) who found `relaxed'
students to have experienced their ®rst dental `trauma' at a later age than anxious ones. The
extra years of stress free dentistry appears to inhibit the perception of `trauma'. Whether this
process, known as latent inhibition, operates amongst a younger population requires
investigation.
The modelling pathway has been supported by a study with adult dental phobics: 13% traced
their fear back to a vicarious experience in childhood (Ost & Hugdahl, 1985). Mothers appear
to be the most likely candidates from which phobics model fear (Muris, Steerneman,
Merckelbach, & Meesters, 1996). A series of studies (Johnson, Dewitt & Baldwin, 1968;
Johnson & Baldwin, 1969; Johnson & Machen, 1973; Wright & Alpern, 1971; Koenigsberg &
Johnston, 1975) consistently discovered a strong link between maternal trait anxiety and
children's anxious behaviour. These results have been interpreted as support for modelling
(Wright, Lucas & McMurray, 1980; Winer, 1982; Kent & Blinkhorn, 1991; Veerkamp,
Gruythysen, van Amerongen & Hoogstraten, 1992). However, modelling involves learning by
direct observation of behaviour (Bandura, 1969; Rachman, 1977) and direct observation of
maternal anxiety in the dentist's room had not actually taken place in these studies, since the
 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 33

children were separated from their mothers during their dental appointment. Similar criticism
(Litt, 1996) has been voiced against the assumption that modelling may be evidenced through
simply correlating self-reported child and parent dental fear (Milgrom et al., 1995). The role of
modelling may be better understood once maternal behaviour has actually been assessed in the
dentist's room.
The information pathway to fear has been investigated by asking children whether they had
heard or seen `frightening' things from the media, school or home (Ollendick & King, 1991) or
whether they knew people who were very scared of a particular situation (Bedi, Sutcli€e,
Donnan & McConnachie, 1992b). Ollendick and King (1991) found that common childhood
fears often stemmed from threatening information, unfortunately dental fear was not included
in the study. Although the informational pathway has been acknowledged in dental fear
studies (Milgrom et al., 1995; Litt, 1996) it has not been studied empirically. The only
exception is Bedi et al. (1992b) who found high levels of dental fear amongst adolescents who
knew a large number of dental phobics. Bedi et al. (1992b) did not consider the other two
pathways in this study, and so their relative contributions remain to be charted.
Dispositional factors may also exacerbate a child's tendency to acquire fear. Certainly general
fears appear to correlate highly with dental fear (Melamed & Cuthbert, 1982; Brown et al.,
1986; Murray et al., 1989; Bedi et al., 1992b; Klinberg et al., 1995; Milgrom et al., 1995).
Gender may be another dispositional factor as females tend to report a higher level of dental
fear (Wright et al., 1980; Murray et al., 1989; Liddell, 1990; Bedi et al., 1992b). This tendency
may derive from underlying biological di€erences (Bowlby, 1975; Wright et al., 1980).
Alternatively, gender di€erences may merely re¯ect a response bias, as fearfulness is more
socially acceptable amongst girls. Unfortunately recent studies only assess children's self-
reported levels of dental anxiety (Wright et al., 1980; Kleiman, 1982; Brown et al., 1986;
Murray et al., 1989; Bedi et al., 1992a,b; Klinberg et al., 1995). A study which provides self-
reported and independent assessment of anxiety should prove informative.
In conclusion, research into the development of dental fear in children has identi®ed a
number of aetiological factors. There is still, however, a need for a study in which all factors
are taken into account together and in which dental anxiety is assessed by the examining
dentist who actually has to manage the child's anxious behaviour. The present study aimed to
redress these issues.

2. Method

2.1. Subjects

Sixty new patients attending a paediatric consultation clinic at Glasgow Dental Hospital and
School and their parents took part. This clinic serves children whose anxious behaviour has
impeded their own dentist's treatment, or, who require consultation regarding a more technical
or medical problem (for example, orthodontic work or unusual gum disease). The behaviour in
the dental hospital (as appraised by the examining dentist) was considered as a more reliable
index of the child's anxiety level than reason for referral, as anxiety criteria were standardised
within the dental hospital team but not amongst the referring community dentists. Therefore,
34 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

children's allocation to the anxious or nonanxious group (abbreviated as `A' and `N-A') was
based on the examining dentist's assessment. Two age groups participated in this study: 7±10-
year-olds (`young' or `Y') and 11±14-year-olds (`old' or `O'). The average age of the anxious
and nonanxious children did not signi®cantly di€er (MOA=12.61, MYA=9.36, MON-A=13.12,
MYN-A=9.14. The proportion of girls (`G') to boys (`B') in each group was roughly equal.
Fifty-three children were accompanied by their mother, seven children by another member of
the family.

2.2. Procedure

Data was collected by means of pre- and postappointment structured interviews with
children and parents and by observation during the dental appointment. Interviews consisted
of questionnaire administration to parents and verbal questioning of children who responded
using visual cues. Prior to the appointment: parental dental and state anxiety was assessed.
Children were questioned about their: dental anxiety, previous dentist's empathy, knowledge of
dentally fearful information and asked to estimate parental anxiety regarding this appointment.
During the appointment, maternal behaviour was observed and recorded at three points in
time (before the examination, during the examination and after the examination). After the
appointment, children's general fear was assessed. Meanwhile, parents completed a trait
anxiety measure and a short questionnaire regarding their child's past dental experiences. The
examining dentist rated the child's dental anxiety and recorded dental pathology data.

2.3. Measures

2.3.1. Child dental anxiety

Children's anxious behaviour in the dentist's room was rated by the examining dentist on a
10-cm visual analogue scale which has been recommended for use in child dental fear studies
by Hosey and Blinkhorn (1995). The extreme ends indicated high and low anxiety.
A pictorial version of the Dental Anxiety Scale (DAS, Corah, 1969) was designed to measure
the self-reported level of child dental anxiety. A `fear of injection' item was added to the
original four DAS items as injections are highly feared by child dental patients (Alvesalo et al.,
1993; Milgrom et al., 1995). Scores on the pictorial anxiety scale (PAS; Townend, 1997) could
range from 5 (`relaxed') to 25 (`very frightened') and the Cronbach's a was 0.83.

2.3.2. Conditioning measures

Objective conditioning was estimated by indices of children's dental pathology: decayed teeth
totals (DT) missing teeth totals (MT) ®lled teeth totals (FT) and a total score of pathology
(DMFT). This method (DMFT, Klein & Palmer, 1937) is globally used (Pine, 1997).
Subjective conditioning was assessed by parental reports of the number of `traumatic or
painful' dental visits experienced by their child. They were also asked to indicate the child's age
at the ®rst `traumatic' visit (if relevant) so that latent inhibition could be tested.
Dentist's empathy, as perceived by the children, was assessed by a modi®ed version of the
Dental Beliefs Survey (DBS, Smith, Getz, Milgrom & Weinstein, 1987). A paediatric dental
consultant selected ®ve items and the language was adapted for the children. A 5-point Likert-
 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 35

type scale was used, so scores could vary between 5 (very insensitive to the child's needs) and
25 (very sensitive to the child's needs). Cronbach's a of this scale was 0.63.

2.3.3. Modelling measures

Parental dental anxiety was assessed by the Dental Anxiety Scale (DAS, Corah, 1969).
Cronbach's a of this scale was 0.89.
Parental anxiety at the dental hospital was measured by the State Anxiety Scale of
Spielberger, Gorsuch and Luchenes (1970). General parental anxiety was measured by the Trait
Anxiety Scale of Spielberger et al. (1970).
Parental behaviour during the dental appointment was assessed by a modi®ed Dyadic
Prestessor Interaction Scale (DPIS, Bush, Melamed, Sheras, & Greenbaum, 1988) the following
seven behavioural dimensions were found to adequately describe maternal behaviour during a
pilot study. (1) ®ne motor agitation, (2) ignoring, (3) empathetic comment, (4) empathetic
gesturing, (5) humorous gesturing, (6) information to the child and (7) information to the
dentist.
Children's sensitivity to parental concern regarding the dental visit was assessed by obtaining
their estimations of parental `worry'. They responded on a 10-point visual analogue scale,
labelled `very worried' at one end and `not at all worried' at the other.

2.3.4. Information
Children's knowledge base of frightening dental information was explored using questions
referring to school and personal experiences. Firstly, they were asked to indicate whether they
had learned about dental care and procedures at school, and if so whether this was unsettling.
Secondly, whether dental fear had been speci®cally discussed in the classroom. Lastly, whether
they knew any friends or relatives who were dentally fearful (Bedi et al., 1992b).

2.3.5. Background/disposition
Children's gender, age (in years) and postcode were obtained from their dental records.
Following research by Carstairs and Morris (1991) Scottish post codes can be used as a
deprivation index, ranging from 7 (highest level of deprivation) and 1 (lowest of deprivation).
Children's general fear level was assessed by a modi®ed version of the Fear Survey Schedule
II (FSS-II) by Hakeberg, Gustafasson, Berggren and Carlsson (1995). Six items were omitted
from the questionnaire because they either overlapped with dental fear or referred speci®cally
to adults scenarios (e.g. losing a job). Language of some items was simpli®ed to suit the
younger children (death, social life and other people were changed to graveyards, friendships
and strangers respectively). Cronbach's a of this scale was 0.78.
Following the suggestion of Murray et al. (1989), the children's self-ecacy was assessed by
asking children how sure they were that they would be `well behaved' in the dentist's room.
They responded on a 10 point scale, labelled `very sure' at one end and `not at all sure' at the
other.

2.4. Data analysis

Mean di€erences between anxious and non anxious children were compared by a three-way
36 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

analysis of variance (gender  age  dental anxiety group) followed by Tukey's honestly
signi®cant di€erence test. Alternatively, Mann Whitney U or w 2 test was used when parametric
methods were not suitable. Gender di€erences between dentist ratings and self-report measures
of child dental anxiety were investigated using a MANOVA (mode: dentist vs. child, gender,
age and anxiety group).
Pearson correlation coecients were calculated to test for association between relevant
variables.
Finally a stepwise regression analysis was performed using dentist's rating as the criterion.

3. Results

3.1. Dental fear level

Reason for referral demonstrated high concordance with the dentist's appraisal of the
children's behaviour during their dental appointment, r = 0.91, p < 0.001, (see Fig. 1). w 2
analysis of dentists rating (5 and above, versus below 5) against referral category (due anxiety,
versus other reason) obtained agreement in 95% of the time (w 2=48.60, p < 0.001).
In the subsequent analyses the dentist ratings were used as the criterion to distinguish
between anxious (5±10) and nonanxious (0±5) children.

3.2. Objective conditioning

Regardless of age or gender, anxious children generally presented more dental ill health, as
measured by the combined pathology index (DMFT), F(1, 52)=18.56, p < 0.001, see Table 1.
Analysis of each separate pathology index produced mixed results. The number of ®llings (FT)
did not discriminate between anxious and nonanxious children, even when controlling for

Fig. 1. Examining dentists' ratings by reason for referral.

 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 37

Table 1
Means and S.D.s of measures concerning objective and subjective conditioning, modelling, information and disposi-
tion across anxiety and age groups

Variable Anxiousa Nonanxiousa

young old young old

Objective conditioning
Decay totals 4.07 (2.67) 5.87 (3.60) 2.31 (2.50) 1.20 (1.74)
Missing totals 2.79 (2.91) 0.67 (1.11) 0.88 (1.54) 0.93 (1.49)
Filled totals 0.50 (0.76) 1.15 (2.61) 0.69 (1.35) 0.80 (1.32)
DMF totals 7.14 (4.24) 8.00 (4.67) 3.88 (3.44) 2.67 (2.64)

Perceived conditioning
No of `traumatic' visits 1.36 (0.93) 2.13 (1.06) 0.50 (0.817) 0.53 (0.64)
Dentists empathy 15.86 (4.02) 16.33 (3.35) 19.50 (3.67) 20.20 (3.63)
Latent inhibition (in years) 2.16 (2.05) 3.77 (3.17) 1.03 (1.86) 1.43 (2.56)

Modelling
Maternal dental anxiety 10.93 (4.10) 9.33 (3.74) 8.83 (2.33) 10.58 (3.03)
Maternal trait anxiety 41.65 (9.91) 38.60 (8.25) 39.42 (9.00) 36.67 (8.94)
Maternal state anxiety 41.86 (11.08) 42.20 (13.40) 33.75 (9.06) 34.00 (9.41)
Child's perception of her anxiety 2.57 (2.79) 2.87 (2.67) 2.00 (2.45) 1.80 (1.32)
Maternal ®ne motor agitation 0.93 (0.83) 1.33 (1.05) 0.67 (0.90) 0.50 (0.67)
Maternal ignoring behaviour 1.07 (0.83) 1.13 (1.06) 0.33 (0.49) 0.42 (0.90)
Maternal empathetic comments 0.29 (0.47) 0 0.33 (0.62) 0.33 (0.89)
Maternal empathetic gestures 1.65 (0.84) 1.40 (0.91) 0.80 (1.08) 1.17 (1.03)
Maternal humorous gestures 1.14 (1.17) 0.33 (0.49) 1.13 (1.25) 0.67 (0.89)
Maternal information to children 0.57 (0.65) 0.87 (1.06) 0.40 (0.74) 0.08 (0.29)
Maternal information to dentists 1.07 (0.73) 0.80 (0.68) 1.20 (0.78) 1.33 (1.07)

Information
Number of anxious others known 1.86 (3.18) 0.73 (0.96) 0.69 (1.01) 1.47 (1.89)
Dental hygiene education 0 0 0 0
Dental fear education 0 0 0 0

Background and disposition

Age (in years) 9.36 (1.27) 12.74 (1.15) 9.15 (1.21) 12.99 (1.23)
Deprivation category 5.31 (1.25) 4.87 (1.73) 4.60 (1.99) 3.60 (2.20)
General fear 42.79 (8.25) 32.40 (8.25) 35.81 (11.14) 33.00 (7.92)
Behavioural self ecacy 7.93 (3.34) 7.60 (3.20) 8.44 (3.27) 9.07 (2.40)

a
Mean (S.D.).

gender and age. However, signi®cant results were obtained for dental decay and missing totals.
Dental decay (DT) results mirrored those for the total DMFT index, as decay was reported
signi®cantly more in anxious than in nonanxious children, F(1, 52)=20.11, p < 0.001. The
analysis of missing teeth (MT) demonstrated an interaction e€ect, whereby higher missing
38 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

totals were observed for anxious children only in the younger age group (Tukey HSD T(4,
52)=1.82, p < 0.05).

3.3. Subjective conditioning

Subjective conditioning, as assessed by the number of `traumatic' experiences reported for

each child, discriminated between anxiety groups. Anxious children, independent of age and
gender, had experienced signi®cantly more traumatic visits to the dentist than nonanxious
children, F = 28.55, p < 0.001, i.e. on average three times more (MA=1.73, MN-A=0.50).
Most children, whether anxious or nonanxious, rated their past dentists as having been fairly
sensitive to their needs (see Table 1). However, analysis revealed that nonanxious children
perceived their dentists to be signi®cantly more empathetic (F = 14.95, p < 0.0001).
Anxious and nonanxious children also di€ered signi®cantly, F(1, 52)=6.42, p < 0.01), in the
time interval that had elapsed between their age at the ®rst `traumatic' dental visit and the
interview (latent inhibition). The anxious children had encountered their ®rst traumatic
experience earlier on in life than nonanxious children, regardless of their age and gender.

3.4. Modelling

Fifty-three children attended with their mother and seven with a variety of other family
members, therefore analysis regarding parental variables was limited to the maternal group.
Self-reported maternal dental anxiety scores were unable to discriminate between gender, age
or anxiety grouping (MA=10.24 and MN-A=9.50), and correlation between maternal dental
anxiety scores and dentist ratings of child dental anxiety was extremely low, r = 0.01.
However, when children's and mother's self-reported scores were compared an associative
relationship was found (rA=0.45, p < 0.05, rN-A=0.64, p < 0.001).
Analysis of maternal state and trait anxiety revealed only one signi®cant di€erence: mothers
of anxious children reported higher levels of state anxiety than mothers of the nonanxious
children, F(1, 45)=6.46, p < 0.05 (MA=42.4 and MN-A=33.4). In contrast, children indicated
that they believed mothers to be `not at all worried' by giving a modal response of 1/10.
Anxious children's perceptions of maternal worry were not signi®cantly higher than
nonanxious children's, U = 378.5, z = 1.02, p > 0.05.
Mothers of the anxious children did tend to behave di€erently in some ways. Mann Whitney
U tests showed that they displayed more agitation (U = 262.0, z = 2.26, p < 0.05) and were
more likely to ignore the children (U = 211.5, z = 3.21, p < 0.005). Yet they were more likely
to make empathetic gestures (U = 263.5, z = 2.19, p < 0.05) and provide their children with
information about dentistry (U = 264.5, z = 2.46, p < 0.01). The levels of empathetic
comments, humorous gestures and information giving to the dentist were not signi®cantly
di€erent across mothers of anxious and nonanxious children.
Two thirds of the mothers of anxious children (67%) reported having attempted to allay
their children's fear prior to the dental visit: most used discussion and reassurance, while a
minority reported bribery tactics. Dentists assessment of the anxious children at the visit did
not appear in¯uenced by maternal e€orts to allay children's fears beforehand
(MAllay attempt=7.45, MNo attempt=8.06).
 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 39

3.5. Information

Whether children knew other people who were afraid of dentistry did not appear to
contribute to their own dental anxiety in this study (U = 439.0, z = 0.168, n.s.).
Children unanimously reported that they had received no dental health or fear education at
school.

3.6. Background/disposition

A main e€ect for deprivation category was observed, F(1, 50)=4.67, p < 0.05. Anxious
children were found to live in more deprived areas than nonanxious ones (MA=5.07,
MN-A=4.10).
The children's self-reported anxiety produced a rather complex picture. There was a
signi®cant three-way interaction between mode of fear assessment (dentist rating versus self-
report) with gender and age, F(1, 52)=5.28, p < 0.05. While dentist ratings were very similar
across gender and age, children's own reports di€ered (see Fig. 2). Older girls admitted to a
higher level of dental fear (MO-G=53.89) than all other groups (MO-B=24.58, p < 0.01, MY-
B=30.94, p < 0.01, MY-G=33.21, p < 0.01). In contrast, older boys considered themselves to
be less fearful than the others, although they did not appear this way to the dentists
(MSelf report=24.58, MDentist rating=41.58, p < .0.01). However, overall a child self-report
correlated moderately well with dentist rating (r = 0.60, p < 0.001).
Children's general fear did not discriminate between dentally anxious and nonanxious
children. However, a main e€ect for age was observed, F(1, 52)=1.88, p < 0.01, demonstrating
that the younger children were signi®cantly more generally anxious than the older children
(MY=36.12, MO=25.46).
The children's degree of self-ecacy did not di€er between young and old children, boys or
girls or anxious and nonanxious patients.

Fig. 2. Gender and age di€erences across children's self reports and dentists' ratings of dental anxiety.
40 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

3.7. Regression analysis

Each of the predictor variables were correlated with dentist ratings of the children's anxious
behaviour. Those variables which were signi®cant, were entered into a multiple regression
analysis (as the measures of DMFT and DT overlap, only DT was entered). A stepwise design
was used whereby signi®cance at the 0.05 probability level is required for a variable to be
entered, and variables already in the equation must retain a minimum signi®cance level of 0.10
to stay in the model. The results are summarised in Table 2. Only three variables contributed
signi®cantly to the ®nal multiple correlation of R = 0.71, p < 0.0001. Two conditioning
variables (`number of traumatic visits' and `dentist empathy') were responsible for 93% of the
explained variance. This demonstrates the importance of children's subjective experience with
dentistry. Overall, the regression produced a weaker support for the modelling variables.
However, `maternal state anxiety' was able to o€er a unique and signi®cant contribution to the
®nal equation, bringing the total explained variance to over 50% of the total variance.

4. Discussion

The study investigated factors contributing to the development of dental fear in children
who were attending a paediatric consultation clinic for specialised treatment. The level of
dental fear was estimated by the examining dentist, and the children were split into two
groups, anxious or nonanxious. The results showed that Rachman's three pathways to fear
development, were helpful in explaining the aetiology of dental fear in children (i.e.
conditioning, modelling and information). The strongest association was with the conditioning
pathway, followed by the modelling pathway. The information pathway and the child's own
disposition and background only played minor roles.
The conditioning pathway to dental fear could be traced back to both, objective dental

Table 2
Stepwise linear regression results for dentist ratings of child dental anxiety

Variables Beta value T value Signi®cance of T Cumulative multiple R

Variables in the equation

No of `traumatic' visits 0.485 4.530 0.0001 0.58
Dentists empathy ÿ0.323 ÿ3.030 0.005 0.66
Maternal state anxiety 0.273 2.629 0.05 0.71

Variables not in the equation

Deprivation category 0.085 0.759 0.452 ±
Decay totals 0.110 0.819 0.417 ±
Latent inhibition ÿ0.085 ÿ0.619 0.539 ±
Agitation 0.083 0.748 0.458 ±
Looks away 0.074 0.653 0.517 ±
Empathetic gesture 0.163 1.563 0.125 ±
Explanation to child 0.150 1.382 0.174 ±
 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 41

pathology and to subjective dental experiences. Like in many other studies (Shaw, 1975; Bedi
et al., 1992b; Alvesalo et al., 1993; Milgrom et al., 1995) dental pathology was generally higher
in anxious than in nonanxious children, especially the number of missing teeth and the amount
of dental decay.
Recently however, doubts have been cast on the appropriateness of using dental decay
indices as evidence that invasive treatment has occurred which would allow conditioning to
take place (Litt, 1996). Excessive decay, usually taken to indicate long term pathology (Bedi et
al., 1992b) is actually more suggestive of treatment avoidance than treatment experience. Adult
phobics accumulate an abnormally extreme level of disease before seeking treatment (Lautch,
1971; Berggren & Meynert, 1984) similarly to the anxious children in the present study
(approximately ®ve decayed teeth each). Even as adults, many phobic patients still vividly
recall long past dental treatment experiences, often childhood encounters involving intense pain
(Berggren & Meynert, 1984). Association with painful treatment seems to form the basis of the
conditioning pathway to dental fear (Weinstein, 1990). Such willingness to endure toothache in
order to avoid it's cure underscores the strong and persistent in¯uence of early experience later
on in life.
The anxious children in the present study had experienced more traumatic dental visits than
the nonanxious children and they had generally done so at younger ages. Likewise, Shaw
(1975) found that highly anxious children were far more likely to have undergone extraction,
often at their ®rst dental visit when they were still very young. There are a number of reasons
why dental experiences in early childhood are more likely to generate the conditioning of
dental fear.
Younger children will have had fewer positive visits to the dentist prior to their ®rst
unpleasant treatment visit. However, such positive visits appear to inoculate children against
the development of dental fear (Davey, 1989; Liddell, 1990). Weinstein (1990), therefore,
suggested that whenever possible invasive treatment should be postponed until a child is
psychologically ready to cope, and that instead preventative noninvasive methods, should be
used, such as sealants and topical ¯uoride.
Further, a considerable number of dentists are still wary of using local anaesthetic or other
forms of pain reduction (e.g. relative or general anaesthetic, or hypnosis) with young children
(Curzon, Fairpo & Heathcote, 1986; Wright, Geibartowski & McMurray, 1991; McKnight-
Hanes, Myers, Dushku & Davis, 1993). Many dentists are aware of their insucient knowledge
of both pharmacological and psychological techniques which can be used to manage children's
behaviour (Curzon et al., 1986; Wright et al., 1991). Postgraduate training courses could
therefore help to improve paediatric management techniques in the future.
Moreover, the dentist's personal sensitivity to children's fear appears crucial, as the anxious
children considered their past dentist's manner to be less empathetic than the nonanxious
children. Experimental ®ndings suggest that dentists can indeed modulate a child's anxious
behaviour. Melamed et al. (1983) found that criticism had a highly negative e€ect on 4±12-
year-old anxious children. Similarly, Weinstein, Getz, Ratener and Domoto (1982a, 1982b)
reported that coercion and coaxing were countere€ective, while empathy and friendly guidance
achieved much better cooperation from the child. Children do seem to appreciate dentists who
tell them that they will respond to signals of discomfort (Weinstein & Nathan, 1988).
Notwithstanding the importance of empathetic behaviour, ®ndings regarding the actual giving
42 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

of control have been controversial. Corah (1973) reported a reduction of physiological arousal
and anxiety in children who were able to use a red `stop' gadget, whereas Weinstein et al.
(1996) failed to replicate these results, using self-report measures of anxiety.
Altogether, the conditioning process (as expressed in the child's dental pathology, his/her
early dental trauma and his/her dentist's empathetic behaviour) plays an important role in the
development of child dental anxiety. However, for a more complete explanation of dental fear
in children, parental anxieties and behaviours should be taken into account.
A mother is still generally a child's most important care-giver, and she may in¯uence her
child's development of anxious or coping responses in fear provoking situations. Children may
learn from their mothers via modelling, information, reinforcement or even by more subtle
forms of communication (Greenbaum, Cook, Melamed, Abeles & Bush, 1986). In the present
study two methods were used to investigate whether a mother's anxiety may transfer to her
child. Firstly, mothers' behaviour was observed directly, i.e. in the dentist's room while her
child was examined. Secondly, mothers' behaviour was assessed indirectly, i.e. by interviewing
mothers regarding their state and trait anxiety and their own speci®c fear of dentistry.
The behaviour of mothers of nonanxious children was fairly relaxed and calm throughout
the examination. In contrast, the behaviour of mothers of anxious children was more variable.
Often they would visibly withdraw from the ongoing dental investigation (turning away from
the child and the dentist) whilst at other times they would participate more (by gesturing
empathetically to their o€spring or by volunteering explanations about dental procedures).
Previously, Venham, Bengston and Cipes (1978) observed a similar variability in maternal
behaviour at the dental surgery. On occasion they were able to facilitate their children's
cooperation, but at other times they were rather less e€ective, particularly, when the child's
behaviour was extreme. This paradox in maternal behaviour may explain why many studies
found that maternal presence or absence in the dental room had no overall signi®cant e€ect on
children's anxiety level (e.g. Pfe€erle, Machen, Fields & Posnick, 1982). Maternal e€orts to
allay children's dental fears before the visit were also found to be of insigni®cance. Similar
results were obtained by Veerkamp et al. (1992) in which mothers themselves reported feeling
that their previsit e€orts had been in vain.
Even if mothers' overt behaviour did not seem to in¯uence their children's behaviour during
the dental examination, they still may have communicated their anxiety indirectly. Indeed,
mothers of anxious children were signi®cantly more anxious than mothers of nonanxious
children during the dental visit (State Anxiety) which ostensibly supports a process of
emotional contagion between mothers and children (Bush et al., 1988). However, mothers of
anxious children were not more anxious in everyday life (Trait Anxiety). Therefore it seems to
be that their temporarily high level of anxiety experienced during the dental appointment was a
sign of empathy with their children's anxiety and not the other way round. This idea is
supported by the children's ignorance of their mothers' feelings, most of them believed their
mothers to be not at all worried.
Some of the children's fear of dentistry may have resulted from the mothers unwitting
provision of frightening information (Muris et al., 1996). Indeed the signi®cant correlative
relationship between children and their mothers dental anxiety suggests that they have at least
absorbed maternal attitudes to dentistry. However the present study found no other evidence
that children had become fearful via the informational pathway. Despite the recent extensive
 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 43

campaign by the Scottish Health Board (The Scottish Oce, 1995) none of the children
recalled ever having discussed dental hygiene or dental fear at school. Surprisingly, in contrast
to the ®ndings of Bedi et al. (1992b), anxious children were not more likely to know people
afraid of the dentist than nonanxious children. In fact, over half of the children had never met
a dentally fearful person.
Social economic class was the only background/disposition factor which seemed to
exacerbate children's dentally fearful behaviour. Anxious children came more from deprived
areas than nonanxious children. This result may seem disappointing as all children in Scotland
are entitled to the same quality of free dental care. Nevertheless, there is actually a strong
relationship between social class and dental health in Scotland (Sweeney, 1997) which seems to
be due to dietary and dental habits (Bedi, Sutcli€e & Balding, 1990). As poor dental health
leads inevitably to more treatment, the link between social class and dental fear becomes
understandable, although it remains a cause for concern (The Scottish Oce, 1995).
Although the present study generally supports the contention that children's dental fear has
resulted from learning (Rachman's three pathways) and not from dispositional factors, an
interesting gender relationship was observed. Older girls admitted to much higher levels of
dental fear, in contrast, older boys (especially the anxious ones) tended to underplay their
worries about the forthcoming dental examination. This pattern of results is not unusual in
studies where self-report measures are used (Wright et al., 1980; Murray et al., 1989; Bedi et
al., 1992a Bedi et al., 1992b; Klinberg et al., 1995; Milgrom et al., 1995). However,
Duivenvoorden et al. (1985) believe that there is no real di€erences in the level of anxiety
experienced by males and females, but that men will deny dental anxiety more as they are
expected to be stoic. The fact that any gender di€erences went unnoticed by the examining
dentists suggests that children do not necessarily behave according to what they have said (self-
report).
In conclusion, a wide range of measures representing Rachman's three pathways and the
children's background and disposition were studied in relation to the children's level of dental
fear. Half of these measures discriminated successfully between clinical and low dental anxiety.
However, in the ®nal (multiple regression) analysis the unique contributions of only three
variables produced a fairly robust model (R = 0.71). These three variables were: the number of
`traumatic/painful' dental visits, dentist's empathy and maternal state anxiety.
While Rachman's three pathways were found to act synergistically to produce the subclinical
fears of children in the Ollendick and King (1991) study, our results favour conditioning as the
route to clinical child dental anxiety. Within the conditioning pathway, subjective trauma and
experiences of pain turned out to be more predictive than objective dental pathology. This
result is consistent with current understanding of pain as a complex perception and not a
purely physical sensation (Melzack & Wall, 1988). Additionally, a child's perception of the
dentist appears to be important, as dentist's empathy proved the second most signi®cant
contributor to the regression equation. Notwithstanding, the contention of Steen (1891), that
the treatment of a child involves not just two persons, but a triangle of personalities, our data
suggests that the dentist's in¯uence on the child outweighs that of the mother. As the only
modelling variable to enter the regression analysis was the mother's state anxiety, it should also
be kept in mind that the mother±child link may be mostly one-directional, i.e. temporary and
appropriate concerns for the child's predicament.
44 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

The present results support recommendations (National Dental Advisory Committee, 1998;
Poulton, Thomson, Brown & Silva, 1998) for improving dentists' awareness of children's
psychological needs in order to prevent the development of fear and its subsequent detrimental
e€ect on dental health. Any future informational campaigns designed to encourage better
dental health behaviours amongst children must aim to engage their attention more e€ectively.
In future, research should identify the speci®c stimuli involved in children's dental fear
conditioning. Furthermore there is a need to address the issue of intervention and whether
dentist's empathetic behaviour may prove as important to the recovery of child patients as it
appears to be with adults (Smith et al., 1987).

Acknowledgements

We would like to warmly thank the sta€ in the children's department at Glasgow Dental
Hospital and School for their invaluable participation in this study.

References

Alvesalo, I., Murtomaa, H., Milgrom, P., Honkanen, A., Karjalainen, M., & Tay, K. M. (1993). The Dental Fear
Survey Schedule: a study with Finnish children. International Journal of Paediatric Dentistry, 3, 193±198.
Bandura, A. (1969). Principles of behaviour modi®cation. London: Holt, Rhinehart & Winston.
Bedi, R., Sutcli€e, P., Donnan, P. T., Barret, N., & McConnachie, J. (1992a). Dental caries experience and preva-
lence of children afraid of Dental treatment. Community Dentistry and Oral Epidemiology, 20, 368±371.
Bedi, R., Sutcli€e, P., Donnan, P. T., & McConnachie, J. (1992b). The prevalence of Dental anxiety in a group of
13- and 14-year-old Scottish children. International Journal of Paediatric Dentistry, 2, 17±24.
Bedi, R., Sutcli€e, P., & Balding, J. W. (1990). Dental Health related behaviour of Scottish and English Secondary
School children. Community Dental Health, 7, 149±156.
Berggren, U., & Meynert, G. (1984). Dental fear and avoidance: causes, symptoms and consequences. Journal of the
American Dental Association, 109, 247±251.
Bowlby, J. (1975). In Attachment and loss. 2. Separation, anxiety and anger (pp. 219±274). Hammondsworth:
Penguin Books.
Brown, D. F., Wright, F. A. C., & McMurray, N. E. (1986). Psychological and behavioural factors associated with
dental anxiety in children. Journal of Behavioural Medicine, 9, 213±218.
Bush, J. P., Melamed, B. G., Sheras, P. L., & Greenbaum, P. E. (1988). Mother±child patterns of coping with antici-
patory medical stress. Health Psychology, 5, 137±157.
Carstairs, V., & Morris, R. (1991). Deprivation and health in Scotland. Aberdeen: Aberdeen University Press.
Corah, N. L. (1969). Development of a Dental Anxiety Scale. Journal of Dental Research, 48, 596.
Corah, N. L. (1973). The e€ect of perceived control on stress reduction in pedodontic patients. Journal of Dental
Research, 52, 1261±1264.
Curzon, M. E. J., Fairpo, C. G., & Heathcote, D. (1986). The use of paedodontic techniques by general dental prac-
titioners and community dental ocers: a survey in Yorkshire. Journal of Paediatric Dentistry, 2, 13±19.
Davey, G. C. L. (1989). Dental phobias and anxieties: evidence for conditioning processes in the acquistion and
modulation of a learned fear. Behaviour Research and Therapy, 22, 51±58.
Duivenvoorden, H. J., Schuurs, A. H. B., Van Velzen, T. S. K., Verhage, F., Makkes, P. C., & Eijkman, M. A. J.
(1985). In¯uence of repression upon the measurement of dental anxiety. Community Dentistry and Oral
Epidemiology, 13, 315±318.
 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46 45

Eli, I., Uziel, N., Baht, R., & Kleinhauz, M. (1997). Antecedents of dental anxiety: learned responses versus person-
ality traits. Community Dentistry and Oral Epidemiology, 25, 233±237.
Greenbaum, P. E., Cook, E. W., Melamed, B. G., Abeles, L. A., & Bush, J. P. (1986). Sequential patterns of medi-
cal stress: maternal agitation and child distress. Child and Family Behaviour Therapy, 10, 9±18.
Hakeberg, M., Gustafasson, J. E., Berggren, U., & Carlsson, S. G. (1995). Multivariate analysis of fears in dental
phobic patients according to a reduced FSS-ll scale. European Journal of Oral Sciences, 103, 339±344.
Hosey, M. T., & Blinkhorn, A. S. (1995). An evaluation of four methods of assessing the behaviour of anxious child
dental patients. International Journal of Paediatric Dentistry, 5, 87±95.
Johnson, R., & Baldwin, D. C. (1969). Maternal anxiety and child behaviour. Journal of Dentistry for Children, 36,
87±92.
Johnson, R., Dewitt, C., & Baldwin, D. C. (1968). Relationship of maternal anxiety to the behavior of young chil-
dren undergoing dental extraction. Journal of Dental Research, 47, 801±805.
Johnson, R., & Machen, J. B. (1973). Behavior modi®cation techniques and maternal anxiety. Journal of Dentistry
for Children, 41, 272±276.
Kent, G. G., & Blinkhorn, A. S. (1991). The psychology of dental care (2nd ed.). Oxford: Butterworth-Heinemann.
Kleiman, M. B. (1982). Fear of dentists as an inhibiting factor in children's use of dental services. Journal of
Dentistry for Children, 49, 209±213.
Klein, H., & Palmer, C. E. (1937). In Dental caries in American Indian children. In Public Health Bulletin, 239. US
Government Printing Oce.
Kleinhauz, M., Eli, I., Baht, R., & Shamay, D. (1992). Correlates of success and failure in behavior therapy for den-
tal fear. Journal of Dental Research, 71, 1832±1835.
Klinberg, G., Berggren, U., Carlsson, S. G., & NoreÂn, J. G. (1995). Child dental fear: cause-related factors and clini-
cal e€ects. European Journal of Oral Science, 103, 405±412.
Koenigsberg, S. R., & Johnston, R. (1975). Child behavior during sequential dental visits. Journal of the American
Dental Association, 85, 128±132.
Lautch, H. (1971). Dental phobia. British Journal of Psychiatry, 119, 151±158.
Liddell, A. (1990). Personality characteristics versus medical and dental experiences of dentally anxious children.
Journal of Behavioural Medicine, 13, 183±194.
Litt, M. D. (1996). A model of pain and anxiety associated with acute stressors: distress in dental procedures.
Behaviour Research and Therapy, 34, 459±476.
McKnight-Hanes, C., Myers, D., Dushku, J., & Davis, H. (1993). The use of behaviour management techniques by
dentists across practitioner type, age and geographic region. Pediatric Dentistry, 15, 267±271.
Melamed, B. G., Bennett, G., Jerrell, G., Ross, S. L., Bush, J. P., Hill, C., Courts, F., & Ronk, S. (1983). Dentists'
behavior management as it a€ects compliance and fear in pediatric patients. Journal of the American Dental
Association, 106, 324±330.
Melzack, R., & Wall, P. D. (1988). The challenge of pain (2nd ed.). London: Penguin Books.
Milgrom, P., Mand, L., King, B., & Weinstein, P. (1995). Origins of childhood dental fear. Behaviour, Research and
Therapy, 33, 313±319.
Milgrom, P., Vignehsa, H., & Weinstein, P. (1992). Adolescent dental fear and control: prevalence and theoretical
implications. Behaviour, Research and Therapy, 30, 367±373.
Moore, R., Brodsgaard, I., & Birn, H. (1991). Manisfestations, acquisition and diagnostic categories of dental fear
in a self-referred population. Behaviour Research and Therapy, 29, 51±60.
Muris, P., Steerneman, P., Merckelbach, H., & Meesters, C. (1996). The role of parental fearfulness and modelling
in children's fear. Behaviour Research and Therapy, 34, 265±268.
Murray, P., Liddell, A., & Donohue, J. (1989). A longitudinal study of the contribution of dental experience to den-
tal anxiety in children between 9 and 12 years of age. Journal of Behavioural Medicine, 12, 309±320.
National Dental Advisory Committee (1998). The availability and uptake of services for the dentally anxious.
Edinburgh: The Scottish Oce.
Ollendick, T. H., & King, N. J. (1991). Origins of childhood fears: an evaluation of Rachman's theory of fear
acquistion. Behaviour Research and Therapy, 29, 117±123.
Ost, L.-G., & Hugdahl, K. (1985). Acquisition of blood and dental phobia and anxiety response patterns in clinical
patients. Behaviour, Research and Therapy, 23, 27±34.
46 E. Townend et al. / Behaviour Research and Therapy 38 (2000) 31±46

Ost, L.-G. (1987). Age of onset in di€erent phobias. Journal of Abnormal Psychology, 96, 223±229.
Pfe€erle, J. C., Machen, J. B., Fields, H. W., & Posnick, W. R. (1982). Child behavior in the dental setting relative
to parental presence. Pediatric Dentistry, 4, 311±316.
Pine, C. M. (1997). Community oral health. Oxford: Reed Educational and Professional Publishing Ltd.
Poulton, R., Thomson, W. M., Davies, S., Kruger, E., Brown, R. H., & Silva, P. (1997). Good teeth, bad teeth and
fear of the dentist. Behaviour Research and Therapy, 35, 327±334.
Poulton, R., Thomson, M., Brown, H., & Silva, P. A. (1998). Dental fear with and without blood-injection fear: im-
plications for dental health and clinical practice. Behaviour, Research and Therapy, 36, 591±597.
Rachman, S. (1977). The conditioning theory of fear acquisition: a critical examination. Behaviour Research and
Therapy, 15, 375±387.
Shaw, O. (1975). Dental anxiety in children. British Dental Journal, 139, 134±139.
Smith, T., Getz, T., Milgrom, P., & Weinstein, P. (1987). Evaluation of treatment at a dental fears research clinic.
Special Care in Dentistry, 7, 130±136.
Spielberger, C. D., Gorush, R. L., & Luschene, R. E. (1970). Manual for the State-Trait Anxiety Inventory. Palo
Alto, CA: Consulting Psychologists Press.
Steen, W. M. (1891). Our relation to children. Dental Review, 5, 534±537.
Sweeney, P. C. (1997). In The Scottish Health Boards' Dental Epidemiological Programme: deprivation and dental car-
ies status among 12-year-old children in Scotland 1996/1997 (pp. 1±2). Dundee: The Dental Health Services
Research Unit.
The Scottish Oce (1995). In Scotland's health, a challenge to us all: the oral health strategy for Scotland (pp. 3±36).
Edinburgh: Her Majesty's Stationary Oce.
Townend, E. (1997). A comparative study of child dental fear. M.A. hons thesis, University of Glasgow.
Veerkamp, J. S. J., Gruythuysen, R. J. M., Van Amerongen, W. E., & Hoogstraten, J. (1992). Dental treatment of
fearful children using nitrous oxide. 2. The parent's point of view. Journal of Dentistry for Children, 59, 115±119.
Venham, D., Bengston, D., & Cipes, M. (1978). Parent's presence and the child's response to dental stress. Journal
of Dentistry for Children, 45, 37±41.
Weinstein, P. (1990). Breaking the worldwide cycle of pain, fear and avoidance: uncovering risk factors and promot-
ing prevention for children. Annals of Behavioral Medicine, 12, 141±147.
Weinstein, P., & Nathan, J. E. (1988). The challenge of fearful and phobic children. Dental clinics of North America,
32, 667±693.
Weinstein, P., Getz, T., Ratener, P., & Domoto, P. (1982a). Dentists' responses to fear- and non-fear-related beha-
viors in children. Journal of the American Dental Association, 104, 38±40.
Weinstein, P., Getz, T., Ratener, P., & Domoto, P. (1982b). The e€ect of dentist's behaviors on fear-related beha-
viors in children. Journal of the American Dental Association, 104, 32±38.
Weinstein, P., Milgrom, P., Hoskuldsson, O., Golletz, D., Je€cott, E., & Koday, M. (1996). Situation-speci®c child
control: a visit to the dentist. Behaviour Research and Therapy, 34, 11±21.
Winer, G. A. (1982). A review and analysis of children's fearful behaviour in dental settings. Child Development, 53,
1111±1133.
Wright, F. A. C., Geibartowski, J. E., & McMurray, N. E. (1991). A national survey of dentists' management of
children with anxiety or behaviour problems. Australian Dental Journal, 36, 378±383.
Wright, F. A. C., Lucas, J., & McMurray, N. (1980). Dental anxiety in 5±9-year-old children. The Journal of
Pedodontics, 4, 99±115.
Wright, G. Z., & Alpern, G. D. (1971). Variables in¯uencing children's cooperative behavior at the ®rst dental visit.
Journal of Dentistry for Children, 38, 124±128.