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Comprehensive Psychiatry 67 (2016) 46 – 53
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Predictors of dental anxiety in Brazilian 5–7 years old children

Fernanda Cunha Soares a,⁎, Rodrigo Antunes Lima b ,
Carolina da Franca Bandeira Ferreira Santos a , Mauro Virgílio Gomes de Barros c ,
Viviane Colares a
a
University of Pernambuco — Post-Graduation Program in Dentistry, Pediatric Dentistry, Recife, Brazil
b
University of Southern Denmark, Odense, Denmark, and Center for Research in Childhood Health; CAPES Foundation, Ministry of Education of Brazil,
Brasília, DF, 70040-020, Brazil
c
University of Pernambuco — Post-Graduation Program in Physical Education UPE/UFPB, Research Group on Lifestyles and Health, Recife, Brazil

Abstract

Objectives: The aim of this study was to analyze the predictors of dental anxiety in 5 to 7-year-old children in a two years follow-up.
Materials and methods: This is a longitudinal study conducted with 784 children with 5 to 7 years old. A face-to-face interview was
conducted with the parents. The Dental Anxiety Question (DAQ) answers were categorized as presence or absence of dental anxiety. The
possible predictor factors analyzed were: related to the children (age, sex, parentage, childbirth, physical activity, body satisfaction,
psychological well-being, physical well-being, dentist visit); and related to the parents or guardians (excessive alcohol consumption, smoke,
family income, number of children). Forward stepwise logistic binary regression was performed for the multivariate analysis. The analysis
was controlled by gender.
Results: The prevalence of dental anxiety was 17.4%. Children in lower family income had 2.3 (95% CI: 1.3–4.0) greater chance to report
high dental anxiety in comparison to children in higher family income. Similarly, children's parents who reported lower psychological well-
being had 1.5 (95% CI: 1.0–3.0) greater chance to report high dental anxiety in comparison to children's parents with higher psychological
well-being.
Conclusions: The prevalence of dental anxiety was high, and the family income and psychological well-being were inversely associated to
dental anxiety in children.
Clinical relevance: Knowing the dental anxiety predictors could help the pediatric dentist to analyze and understand who is more susceptible
to develop dental anxiety. An adequate approach, a trust relationship could be built, improving the oral health conditions and reducing the
need of treatment in children.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction Dental anxiety usually starts in childhood, characterized

Anxiety related to dental treatment is frequently observed
in children [1]. The literature shows that the picture of the
dentist is viewed in a negative way, like a scary person [2].
Therefore, the children go to the dentist office with a big
burden of anxiety. When the dental anxiety becomes an
irrational threatening fear, the dental anxiety has been
established [3].
⁎ Corresponding author at: Universidade de Pernambuco — Reitoria/
UPE, Agamenon Magalhães Avenue, Santo Amaro, Recife, PE, 50100-010,
Brazil. Tel.: +55 81 3183 3674.
E-mail address: fercsoares@gmail.com (F.C. Soares).
http://dx.doi.org/10.1016/j.comppsych.2016.01.006
0010-440X/© 2016 Elsevier Inc. All rights reserved.
by a complex and multifactorial phenomenon [4]. During
childhood, the children experience and internalize situations
from dental anxiety. This feeling can be potentialized by
traumatic events, fear of unknown, feelings of unpredict-
ability, socialization processes, or even learning/imitating his
family [4]. The potential risk factors of dental anxiety are
different from each person; they are consequences of socially
heterogeneous individual background, with individual
personalities, experiences, feelings, expectations, and own
aspirations [4].
Evasion of dentist office, sleep disturbance, low self-esteem
and psychological disorders are some consequences of dental
anxiety [5,6]. The dental anxiety is a big barrier for the
individual oral health care, resulting in harmful consequences,
 F.C. Soares et al. / Comprehensive Psychiatry 67 (2016) 46–53
representing a serious challenge for dentists [7]. Eitner et al.
(2006) reported that the highest level of dental anxiety is
related to the evasion of dental treatment, increasing dental
caries, as well as the DMFS (decayed (D), missing (M), or
filled (F)) indices [8].
Possobon et al. (2007) showed a causal chain in relation
to dental anxiety and avoidance of dental treatment. Patient
with dental anxiety has a tendency to avoid dental treatment,
which leads to an oral health deterioration, requiring more
complex and invasive treatments, increasing the potential of
pain, coming back to dental anxiety, and causing greater
chance to avoid the dental treatment. Therefore, the subject
only accepts treatment when the symptoms of pain become
unbearable [9].
In a cross-sectional study including 970, 5–12 years-old
children, Colares et al. (2013) found a prevalence of dental
anxiety of 14.4%. Additionally, they identified that children
who had toothache had 1.55 higher chances to have dental
anxiety than those who did not felt toothache [1]. Nicolas et al.
(2010) monitored 1303 five to twelve years-old French children
and observed a lower prevalence 7.6% with dental anxiety
(7.6%). Additionally, those who had dental caries or children
who thought they had dental problems were more anxious than
those who did not had caries or thought not have caries [10].
Wogelius et al. (2005) in a cohort study, determined the
prevalence of missed dental appointments among Danish
children with 6–8 years of age and also the association
between dental anxiety and missed dental appointments. The
authors concluded that 37.7% of children missed at least one
dental visit; however, children with dental anxiety had not
higher odds to miss two or more dental visits compared with
children without dental anxiety. In this study only toothache
leads the children to miss two or more dental visits (OR:
2.61; 95% CI: 1.63–4.18) [11].
To reduce the consequences generated by dental anxiety
and adopt an adequate approach it is necessary to identify the
causative factors. Besides caries and toothache as known
associated factors of dental anxiety, there are others factors
that should be investigated, as family income; parents'
consumption of alcohol and smoking; children's physical
activity and screen time; children's body satisfaction; child's
psychological aspects; and frequency of visits to the dentist.
Furthermore, most studies used cross-sectional designs to
analyze dental anxiety correlates which do not allow
inferring about causality. Therefore longitudinal studies are
needed to analyze the possible causes of dental anxiety.
Thus, the objective of this study was to analyze the
predictors of dental anxiety in children 5–7 years by of a
school-based longitudinal study.
2. Materials and methods
2.1. Procedure
A longitudinal study with preschool children aged three to
five years started in 2010. The ELOS-Pre Project (Longitudinal
47
Study of Health and Well-being in Preschool Children) was
designed to assess longitudinal changes in health conditions,
physical activity practices, anthropometric parameters, motor
skill performance and other lifestyle factors among preschool
children and in school age. Baseline data were collected by
graduate students in physical education properly calibrated
between September and November of 2010, in preschools of
Recife, Pernambuco state, Brazil. However, the oral health
evaluation was only included in the first follow-up (September
to November of 2012).
The protocol was approved by the Human Research
Ethics Committee of the University of Pernambuco (protocol
no. 0096.0.097.000-10) and informed written consent was
obtained from the children's parents or guardians and the
respective school principals.
2.2. Participants
The target population of the study at baseline was three to
five-year-old preschool children who were enrolled in both
public and private preschools in the six political administra-
tive regions (PAR) of Recife. A sampling procedure of
clusters in a single stage was adopted for sample selection,
and the school was the sample unit. All schools in Recife
with preschool children were eligible to be included in the
study. Stratification criterion was adopted in order to ensure
that the sample represented the target population regarding
the distribution: type of school (public and private), size
(small: b 50 children enrolled in early childhood education;
medium: 50 to 199 children enrolled; large: 200 children or
more) and the distribution of these according to the six
administrative regions political (RPA). In each selected
school, all regularly enrolled children were invited to
participate in the study [12] (subjects' inclusion criteria)
with 1155 children accepting to participate in the baseline.
After two years, the project has a follow-up rate of 76% (n =
784) (Fig. 1). For the analysis conducted in the present study,
it is possible to detect as significant risk ratio higher than 1.5,
with 95% confidence interval, and statistical power higher
than 80%.
2.3. Measures
2.3.1. Psychological and physical well-being
A standardized face-to-face interview was conducted with
the parents. Four questions were pooled to give a proxy measure
of “psychological well-being” and the “physical well-being”
was obtained pooling other two questions (Table 1).
For the computation of the variables psychological and
physical well-being, it was attributed scores from 1 (lowest
level) to 5 (highest level), then the weighted mean was
calculated and categorized in tertiles.
2.3.2. Physical activity
The time spent in physical activity (games and outdoor
active activities) and screen time (tv, computer and video
games) were computed considering parents' answers in
regard of their child in both activities during morning,
48 F.C. Soares et al. / Comprehensive Psychiatry 67 (2016) 46–53

Fig. 1. Flowchart of longitudinal follow-up of study participants.

afternoon, and evening at the week, and weekend days. For
each period of the day we recorded the time in the categories:
0 min (0), 1–15 min (1), 16–30 min (2) 31–60 min (3) and
more than 60 min (4).
The scores were calculated adding the responses in the
morning, afternoon and evening, with a range from 0 to 12
points. The total score (weekday + weekend day) was
calculated and the amplitude variation was 0–24 points.
Children who reported active time participation in sports and
games outdoor less than 60 min per day were classified as
less active. More detailed description of this measurement
was described by Oliveira et al. (2012) [13,14].
2.3.3. Dental anxiety
Children's dental anxiety was obtained by the Dental
Anxiety Question (DAQ) [15] in which parents were
questioned: “Your child have fear to go to the dentist?”,
with four possible answers: “No”, “Yes, a little bit”, “Yes,
he/she has fear”, and “Yes, he/she has a lot of fear”. The
children were considered with dental anxiety when their
parents informed that they have a lot of fear. From the 784
monitored children, 747 had valid data on the dental anxiety
component. Prior to the study, we have had conducted a pilot
study in which we have tested the reliability test intraex-
aminer for this questioner (Kappa = 0.94) and also, the
reliability test interexaminer (Kappa 0.89) [16].
2.4. Strategy of analysis
Data analyses were performed using SPSS for windows
(version 22). For descriptive purposes crude and relative
frequencies are presented. Differences between categorical
variables were assessed using chi-square test. Forward
stepwise binary logistic regression was performed to
 F.C. Soares et al. / Comprehensive Psychiatry 67 (2016) 46–53 49

Table 1
Composition of the variables: “Psychological well-being” and “physical well-being”.
Variables Questions Possible answers
Extremely
Quite a bit
Limitations for emotional or behavioral problems in the last month
Slightly
Not at all
Deeply unsatisfied
Unsatisfied
Satisfied with the capacity of having friends in the last month Not satisfied neither unsatisfied
Satisfied
Greatly satisfied
Psychological well-being Deeply unsatisfied
Unsatisfied
Satisfied with their life (child) in the last month Not satisfied neither unsatisfied
Satisfied
Greatly satisfied
All of the time
Most of the time
Seem upset or sad Some of the time
A little of the time
None of the time
Extremely
Quite a bit;
Limitations for healthy physical problems in the last month
Slightly
Physical well-being
Not at all
No
Disease
Yes

analyze the predictors of dental anxiety with 5–7 years-old 3. Results

children. Dental anxiety (0: No risk group; 1: Risk group)
was the dependent variable and all the variables with “p
value” lower than 0.25 in the chi-square test entered in the
regression model as independent variables. In the final
regression model (adjusted model II) gender was consid-
ered as a covariate. Statistical significance was set at α =
0.05.
In the Table 2, we present the participants' characteristics
in the baseline (2010), follow-up (2012) and the character-
istics of the participants that we could not follow at 2012
(drop-outs). We had different rates of drop-outs in family
income and in number of children, and to some extent also
for physical as well as psychological well-being.

Table 2
Social and behavioral characteristics of the participants at the baseline (2010), follow-up (2012) and the drop-outs.
Variables 2010 a (n = 1185) Drop-outs b (n = 401) 2012 a (n = 784)

Age Mean (SD) 4.34 (0.75) – 6.39 (0.79)

N % n % n %
Male 594 51.4 188 31.6 406 51.8
Gender
Female 561 48.6 183 32.6 378 48.2
Family income Brazilian ≤2 748 72.0 214 28.6 534 69.1
(Minimum wages) N2 291 28.0 52 17.9 239 30.9
≤2 734 69.4 230 31.3 504 64.5
Number of children (mom)
N2 324 30.6 46 14.2 278 35.5
Normal 559 52.8 143 25.6 416 53.3
Childbirth
Cesarean 500 47.2 135 27.0 365 46.7
1st tertile 321 30.8 64 19.9 257 33.0
Psychological well-being 2nd tertile 454 43.6 124 27.3 330 42.4
3rd tertile 267 25.6 75 28.1 192 24.6
1st tertile 373 35.9 104 27.9 269 34.4
Physical well-being 2nd tertile 416 40.0 81 19.5 335 42.8
3rd tertile 250 24.1 71 28.4 179 22.9
a
Column-wise percentage calculation.
b
Row-wise percentage calculation.
50 F.C. Soares et al. / Comprehensive Psychiatry 67 (2016) 46–53

Table 3
Chi-square test between child information, parental or guardian data, and family data factors at the baseline with dental anxiety at the follow-up.
Dental anxiety
Variables No Yes p
n % n %
Child information
Male 316 80.8 75 19.2
Gender 0.179
Female 301 84.6 55 15.4
3 95 86.4 15 13.6
Age (years) 4 178 82.0 39 18.0 0.580
5 321 82.5 68 17.5
Nature 510 82.3 110 17.7
Parentage 0.346
Adoptive 48 77.4 14 22.6
Normal 293 79.2 77 20.8
Childbirth 0.053
Cesarean 265 84.9 47 15.1
1st tertile 182 79.8 46 20.2
Physical activity 2nd tertile 180 81.8 40 18.2 0.835
3rd tertile 165 81.7 37 18.3
1st tertile 162 79.4 42 20.6
Screen time 2nd tertile 216 83.1 44 16.9 0.537
3rd tertile 150 79.8 38 20.2
No 424 82.7 89 17.3
Body satisfaction 0.296
Yes 128 79.0 34 21.0
1st tertile 150 75.8 48 24.2
Psychological well-being 2nd tertile 255 85.0 45 15.0 0.028
3rd tertile 143 83.1 29 16.9
1st tertile 192 78.7 52 21.3
Physical well-being 2nd tertile 226 85.9 37 14.1 0.082
3rd tertile 131 79.9 33 20.1
No 223 82.3 48 17.7
Dentist visit (last year) 0.740
Yes 330 81.3 76 18.7

Parental factors
b5 103 78.6 28 21.4
Excessive alcohol consumption (doses) 0.472
≥5 119 82.1 26 17.9
No 424 82.7 89 17.3
Smoke 0.296
Yes 128 79.0 34 21.0

Family data
≤2 389 79.1 103 20.9
Family income Brazilian (minimum wages) 0.001
N2 161 89.9 18 10.1
≤2 387 84.1 73 15.9
Number of children (mom) 0.024
N2 171 77.0 51 23.0

In the initial association analyzes with dental anxiety, six out
of 14 variables had p b 0.25 (Table 3) and were tested in the
multiple logistic regression model. Among the predictive factors
tested in the regression model, gender, number of children, and
birth were not predictors of dental anxiety at 5–7 years. Children
in family with until two minimum wages at the baseline had 2.3
times higher odds to have dental anxiety at 5–7 years. In relation
to the psychological well-being, children in lower tertile of
psychological well-being at baseline had 53% higher odds of
having dental anxiety at 5–7 years compared to children in the
highest tertile of psychological well-being (Table 4).
4. Discussion
The present study analyzed comprehensively the predictors
of dental anxiety in 5 to 7-years-old children. The age range at
the baseline (3–5 years) is a differential in this study, because
from the best of our knowledge this is one of the first studies to
analyze dental anxiety in this age group. In preschool age (3–
5 years) is the period which the children's personality is built,
the constitution of the children's personality when the children
learn new skills and establish their behaviors [17]. Since the
6 years of age, the children faces profound social changes,
starts at school, and suffers the social responsibility of being
accepted by peers [18]. In consequence, high levels of anxiety
have been evidenced in these children [19].
The majority of the published papers do not include a big
range of the possible associated factors to dental anxiety in
one single investigation. Therefore, some publications might
have not included important components for a better
understanding of dental anxiety in children [1,19–21].
Another differential of the present paper is the data collection
being performed in the school environment, since the
majority of the studies [3,6,7,17] performed the data
collection in the dentist office which could inflate the
 F.C. Soares et al. / Comprehensive Psychiatry 67 (2016) 46–53 51

Table 4
Binary logistic regression of the predictors of dental anxiety at 6 years old.
Crude model Adjusted model I Adjusted model II
Variable
OR (IC 95%) p OR (IC 95%) p OR (IC 95%) p
Family income (minimum wages)
≤2 2.36 (1.39–4.037) 0.002 2.25 (1.26–4.03) 0.006 2.26 (1.26–4.04) 0.006
N2 1 1 1
Number of children (mom)
≤2 1 1 1
N2 1.58 (1.06–2.36) 0.025 1.47 (0.96–2.24) 0.074 1.45 (0.95–2.23) 0.081
Gender
Male – – 1.15 (0.76–1.73) 0.501
Female 1
Childbirth
Normal 1.48 (0.99–2.21) 0.053 1.29 (0.84–1.99) 0.249 1.30 (0.84–2.01) 0.233
Cesarean 1 1 1
Psychological well-being
1st tertile 1.61 (1.03–2.54) 0.037 1.52 (1.03–2.97) 0.042 1.53 (1.03–2.97) 0.041
2nd tertile 0.99 (0.58–1.69) 0.975 1.06 (0.58–1.95) 0.746 1.06 (0.58–1.96) 0.675
3rd tertile 1 1 1
Physical well-being
1st tertile 1.07 (0.66–1.75) 0.772 0.79 (0.42–1.52) 0.492 0.79 (0.41–1.51) 0.483
2nd tertile 0.65 (0.39–1.09) 0.102 0.59 (0.34–1.04) 0.070 0.59 (0.33–1.04) 0.068
3rd tertile 1 1 1
Adjusted model I — dependent variable + independent variables; adjusted model II — dependent variable + independent variables + gender.

measure of dental anxiety/phobia. Because the children and
the parents outside the dentist office do not suffer the
influence of the dentist environment (i.e. dental instruments,
sounds or the characteristic smell of a dentist office).
Children in lower family income at baseline had two
times higher chance to have dental anxiety at the follow-up
compared to the family with higher income. Previous studies
also demonstrated that higher family income is associated
with lower prevalence of dental anxiety [1,3,5,22–24]. It is
practically consensual that subjects with higher social,
financial, and environmental resources have better health
profiles [25,26]. The association between anxiety and
financial condition might be explained with the fact that
lower income subjects face more problems, not having
leisure opportunities, or education, resulting in higher levels
of anxiety. Therefore, the socioeconomic level could be
faced as a modifier effect between the dental treatment and
anxiety [27]. Another aspect to be considered is the fact that
Brazilian children from lower family income usually receive
dental treatment in the public health system. It is a cultural
flaw the unawareness of how to deal with these children, and
this lack of knowledge leads to a failure approach, leading to
an over valorization of quantitative results, completely
disconnected to an emotional approach. In that way,
emphasizing the need of special attention to lower family
income children in relation to dental anxiety should be
considered by the pediatric dentists [28].
Children with lower psychological well-being (lower
tertile) at baseline had 53% higher chance of having dental
anxiety in the follow-up comparing to children with higher
psychological well-being level (higher tertile). As demon-
strated by Gustafsson et al., study-group patients (dental
anxiety) had significantly fewer close friends, fewer
organized activities, and a nearly four times higher frequency
of personal professional support as compared to the
reference-group patients (no dental anxiety) [24]. The dental
anxiety is associated to the social and emotional well-being
of quality of life [29]. Children with problems in their social
and emotional well-being perceptions generally feel inferior
comparing to their peers, are ashamed of their relatives, and
do not know how to deal with their life problems. Therefore,
these factors could lead to dental anxiety during the dental
treatment [30]. The impulsive temper, challenger, and
intolerant to frustration, associated to cognitive deficits and
inability with social interaction could contribute to inade-
quate behavior, like dental anxiety [31]. Children with social
and emotional problems are silent, sad, friendless, and with
lower academic performance [32]. The pediatric dentist
challenge is to identify these children an intervene aiming to
reduce their dental anxiety. Consequently, dentists with
appropriate approach to children with dental anxiety would
reduce children's dental anxiety, increasing the number of
visits to the dentist and impact in the children's oral health
and well-being.
The prevalence of dental anxiety in 5 to 7-years-old
children was 17.4%. This result is similar to the result
presented by Colares et al. (2013), in which 14.4% of the
children had dental anxiety [1]. The prevalence of children
with dental anxiety is high, deserving attention, because
children with dental anxiety visit the dentist less often,
reflecting a higher possibility of caries, and higher loss of
teeth affected by disease, influencing in their general health
and in their quality of life [10,33–35]. Olak et al. (2013)
confirmed that dental anxiety was highly associated to caries
52 F.C. Soares et al. / Comprehensive Psychiatry 67 (2016) 46–53
and escape of dental treatment in 8 to 10-years-old Estonian
children [36]. Thereby, it is necessary to investigate the
possible causes of dental anxiety related to the dental
treatment aiming to avoid evasion of the dentist office,
increasing the level of children's oral health [36].
Some studies [37,38] mentioned as comparative param-
eter and blurring in the discussion of this study refer to
general anxiety/phobia in children, but the literature shows
that general anxiety is associated to dental anxiety,
consequently the results could be carefully extrapolated. A
limitation of the study is the instrument used to investigate
dental anxiety (DAQ) being applied with the parents what
could lead to answer bias, once the information was not
collected directly from the children. However, this strategy
was adopted because of the age range of our sample. They
could not have the correct understanding of the question and
invalidate the answers. The prevalence of dental anxiety in
the present paper could have been underrated, because the
parents could be ashamed to answer the real situation of their
child. Another fact to highlight is the sample selected for this
study. The children were all from a city of the Brazilian
northeast in a way that the results could not be directly
generalized for children from different cultures. However,
the study is representative of one of the biggest state capitals
of Brazil and possibly the results would be similar if the
study was conducted in another Brazilian capital. Another
point that should be considered in the interpretation of the
results is that we have not collected information about the
children's dental anxiety in the baseline of our study (2010)
which would be ideal. However, it is still valuable to be able
to address the aspects that influence dental anxiety in a
two-year follow-up for preschool children, especially with
the lack of knowledge about dental anxiety associated factors
in this population.
This study has some strengths that should be highlighted.
From the best of our knowledge, this is the first study to
analyze the dental anxiety predictors in the first childhood
with a follow-up of two years. Knowing the dental anxiety
predictors could help the pediatric dentist to analyze and
understand who is more susceptible to develop dental
anxiety. We believe that through the adequate approach, a
trust relationship could be built, improving the oral health
conditions and reducing the need of treatment in children.
5. Conclusion
Preschool children with lower psychological well-being
and lower family income had higher chance to have dental
anxiety after two years (5 to 7 years). The prevalence of
dental anxiety in 5 to 7 years-old children was 17.4%.
Conflict of Interest
The authors have no conflicts of interest to disclose.
Acknowledgment
This study was supported with financial assistance from the
Foundation for Improvement of Higher Education Personnel.
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