DOI: 10.1111/j.1365-263X.2011.01200.
Emotional contagion of dental fear to children: the fathers’
mediating role in parental transfer of fear
AMERICA LARA1, ANTONIO CREGO2 & MARTIN ROMERO-MAROTO1
Departments of 1Dentistry and 2Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
International Journal of Paediatric Dentistry 2012; 22:
324–330
Background. Dental fear is considered to be one of
the most frequent problems in paediatric den-
tistry. According to literature, parents’ levels of
dental fear play a key role in the development of
child’s dental anxiety.
Hypothesis or Aim. We have tried to identify the
presence of emotional transmission of dental fear
among family members and to analyse the differ-
ent roles that mothers and fathers might play con-
cerning the contagion of dental fear to children.
We have hypothesized a key role of the father in
the transfer of dental fear from mother to child.
Design. A questionnaire-based survey (Children’s
Fear Survey Schedule-Dental Subscale) has been
Introduction
Referral of children to a specialized paediatric
dentist is an increasingly accepted practice1.
Children’s fear or anxiety is relatively usual
in dental settings, and it contributes to the
referral of a child to a specialist clinic in
paediatric dentistry1. Other frequent difficulties
are related to children’s behaviour manage-
ment problems, involving negative attitudes
towards dentists and treatments, and disrup-
tive conducts during visits to the dentist’s
office. Behaviour management problems
sometimes are confused with dental fear and
anxiety, and although these concepts are not
synonymous they overlap2.
Dental fear may cause frequent and serious
problems for both dentists and patients, and it
often gives rise to a number of harmful
Correspondence to:
Prof. America Lara, Department of Dentistry, Rey Juan
Carlos University, Faculty of Health Sciences, Avda Atenas
s ⁄ n. Campus Alcorcon, E28922 Alcorcon, Madrid, Spain.
E-mail: america.lara@urjc.es
324 International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
distributed among 183 schoolchildren and their
parents in Madrid (Spain). Inferential statistical
analyses, i.e. correlation and hierarchical multi-
ple regression, were carried out and possible
mediating effects between variables have been
tested.
Results. Our results support the hypothesis that
family members’ levels of dental fear are signifi-
cantly correlated, and they also allow us to affirm
that fathers’ dental fear is a mediating variable in
the relationship between mothers and children’s
fear scores.
Conclusions. Together with the presence of emo-
tional transmission of dental fear among family
members, we identified the relevant role that
fathers play as regards the transfer of dental fear
from parents to children.
effects3 which could aggravate dental situa-
tions because of fear reactions such as avoid-
ance, late cancellations, refusals, crying and
anger4. To this respect, dental anxiety has
been indicated as a potential predictor of den-
tal caries incidence5. In general, dental fear is
a child’s normal reaction to an unknown situ-
ation. Mild fear and anxiety are expected
experiences, consistent with normal develop-
ment, but they may become a concern and
may need treatment when that fear or anxi-
ety is disproportioned to the actual threat6.
Several studies1,2,4,6,7 have proved that
dental fear is often mentioned as being multi-
factorial as it may reflect general predisposi-
tion towards anxiety in the affected child
(trait-anxiety), or other factors related to the
personal characteristics of the child, such as
behavioural avoidance, attention biases, and
negative emotions towards possible threats.
Previous experiences of painful dental treat-
ment strongly predict negative reactions and
behavioural management problems4. Further-
more, issues related to socio-economical
factors, culture, family relationships, child-
 2011 The Authors

rearing, and parental dental anxiety should
also be recognized as influencing child behav-
iour during dental treatment4,6.
Among other factors, it has been well docu-
mented that parental dental fear strongly
correlates with dental fear in their child4,7,8,
and it seems to predispose for fear reactions2.
In spite of the fact that some researches ques-
tion the role of parental anxiety as a factor in
children’s reactions to dental treatment, in
general, it is widely accepted that parents’
anxiety has some influence on their child’s
ability to face dental treatment9. Versloot
et al.10 suggested that the child’s ability to
cope with dental treatment was not only
dependent on the child’s degree of psychologi-
cal and cognitive development but also on
the absence of parental anxiety.
Moreover, the existence of interpersonal
processes and mechanisms related to the
transfer of emotions, including fear, has been
extensively reviewed in the psychological lit-
erature11,12. In this context, our study’s aim
is twofold: first, to try to confirm the associa-
tion between parents’ and children’s levels of
dental fear; and second, to analyse the differ-
ent roles that mothers and fathers might play
concerning the transmission of dental fear to
their children. Based on these points, we
have formulated our first hypothesis:
Hypothesis 1: Dental fear levels are expected
to be positively correlated among family
members; that is, the higher dental fear is for
one of the family members, the higher it will
also be also for the rest of family members.
According to the literature reviewed by
Themessl-Huber et al.13, several studies have
confirmed the existence of a significant rela-
tionship between parental and child dental
fear. Further evidence is, however, needed to
support that parents play an important role in
the aetiology of child dental fear.
From a broader field of research, Bögels
and Phares14 reviewed literature focused on
the father’s role in the aetiology of child anxi-
ety and reached the conclusion that fathers
would play a relevant role – different from
the mother’s – in childhood anxiety. Accord-
ing to these authors, children seem to put
higher weight on father’s responses than on
mother’s responses in the face of possible
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
Emotional contagion of dental fear to children 325
threats, to decide whether the situation is
dangerous or should be avoided, which is
related to the development of subsequent
anxiety14. Drawing from these results and
points, we have established a second hypoth-
esis in which fathers are assumed to play a
key role in the levels of dental fear experi-
enced by children.
Hypothesis 2: Fathers will play a different
role from mothers as regards child dental fear.
To be more precise, we expect that children
will take their fathers as a key source of
information to decide whether a dentistry
related event may be dangerous or not; and
thus fathers’ dental fear level will be a media-
tor variable in the relationship between
mothers and children’s dental fear levels
(Fig. 1).
Material and methods
Sample and procedure
Participants were 183 children (51.4% male,
48.6% female) and their parents. Their aver-
age age was 9.38 years (SD = 1.34), ranging
from 7 to 12 years. These schoolchildren were
recruited for the research at two state schools
located in the south area of the Community
of Madrid (Spain). Collaborating teaching
staff distributed in their classrooms envelopes
containing questionnaires for children and
their parents, detailed instructions for filling it
in (e.g. emphasizing that questionnaires had
to be individually completed, encouraging
honest responses, etc.), attestation of guaran-
tee concerning the anonymous treatment of
data, and parents’ informed consent form.
Father’s
dental fear
level
Mother’s Child’s
dental fear dental fear
level level
Fig. 1. Mediating role of fathers on the relationship
between mothers and children’s dental fear.
326 A. Lara, A. Crego & M. Romero-Maroto
Once the questionnaires were completed,
they were returned in a closed envelope to
the research team via the collaborating
schools. Data were collected between Janu-
ary–February 2010. Response rate was
83.94%.
Ethical approval from the Rey Juan Carlos
University committee for ethics in research as
well as parents’ informed consent and permis-
sions from the schools’ teaching staff were
obtained.
Measures
Children and parents’ dental fear . We used a
Spanish translation of the Children’s Fear Sur-
vey Schedule-Dental Subscale (CFSS-DS)15. This
questionnaire comprises 15 items in which
respondents assess their fear levels when fac-
ing aspects of dentistry consultation ⁄ treat-
ment (e.g. the dentist, injections, drilling,
etc.) as well as other medical issues (e.g.
going to the hospital, white uniforms, etc.) by
using a 5-point Likert scale (1, not afraid at
all; 5, very afraid). Total scorings may range
from 15 to 75 points. Cronbach’s alpha reli-
ability was 0.87 for this scale.
Parents filled in a version of the same scale
adapted to adults. Items’ contents, response
format, and scoring procedure were the same
as for children. Cronbach’s alpha reliability
was 0.88 for mothers and 0.89 for fathers.
Participants were considered to present a
high level of dental fear if their total score
was equal to or above 45 points.
The adaptation of the original scale to
Spanish language was done by following a
procedure of forward and back translation.
Statistics
We calculated basic descriptive statistics
(mean scores and standard deviations) on the
prevalence of dental fear among children and
parents from our sample. Parametric inferen-
tial tests require data normally distributed.
Dental fear values, which presented an asym-
metric distribution, were log-transformed to
guarantee this requirement. Paired samples
t-tests were used to determine whether the
differences on dental fear levels between
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
fathers, mothers, and children were statisti-
cally significant. Assumptions for using paired
samples t-test (i.e. data normally distributed,
interval level of measurement) were previ-
ously checked. Besides, we made a compari-
son of mean values between schoolboys and
schoolgirls’ fear levels (independent samples
t-test) to add evidence to the commonly
obtained result of a higher incidence of dental
fear among girls. These possible differences in
dental fear prevalence would support the use
of this variable–gender as a control variable
for subsequent analysis. Levene’s test
(F = 1.10, P > 0.05) confirmed that the
assumption of homogeneity of variances,
required for using an independent samples
t-test, was met.
To test our first hypothesis concerning the
emotional transfer of dental fear between par-
ents and children, we calculated the Pearson’s
correlation between fathers, mothers and
children’s scores.
Finally, we tested our second hypothesis by
performing a hierarchical multiple regression,
following the procedure described by Baron
and Kenny16 for the analysis of mediating
effects between variables. As said before, gen-
der is known to have an influence on chil-
dren’s fear levels – and our results confirmed
this point – so this variable was controlled
when carrying out regression analysis. Baron
and Kenny’s16 procedure involves to carry
out several regression analyses. First, the out-
come variable (children’s dental fear) is
regressed on the independent variable (moth-
ers’ dental fear). Second, the mediator
(fathers’ dental fear) is regressed on the inde-
pendent variable (mothers’ dental fear).
Third, the outcome variable (children’s dental
fear) is regressed on the independent (moth-
ers’ dental fear) and mediator (children’s den-
tal fear) variables. Evidence for a complete
mediation effect requires that the indepen-
dent variable (mothers’ dental fear) loses its
significant effect on the outcome variable
(children’s dental fear) when the mediator
variable (fathers’ dental fear) is included in
the final regression model. Therefore, to con-
firm our hypothesis concerning a mediating
effect, three results should be obtained. First,
the mother’s fear level should be a significant
 2011 The Authors
 Emotional contagion of dental fear to children 327

predictor of the child’s and the father’s dental Table 2. Regression model showing the mediating effect of
the father’s dental fear on the relationship between the
fear levels. Secondly, the father’s dental fear mother’s and child’s dental fear levels.
should be a significant predictor of the child’s
fear, too. Third, support for a full mediating B SE B b
effect of the father’s dental fear level is
Step 1
obtained if the mother’s dental fear level is Constant 1.46 0.01
not a significant predictor of the child’s fear Gender )0.09 0.02 )0.31*
when we introduce the father’s fear level in Step 2
Constant 1.17 0.10
the regression model, while the father’s den- Gender )0.08 0.02 )0.30*
tal fear remains as a significant predictor of Mother’s dental fear 0.19 0.07 0.20*
the child’s fear. Step 3
Constant 1.01 0.11
Gender )0.09 0.02 )0.32*
Results Mother’s dental fear 0.10 0.07 0.10
Father’s dental fear 0.20 0.07 0.21*
The mothers in our sample reported higher
Dependent variable: Child’s dental fear.
levels of dental fear (M = 31.19; SD = 10.46) Note. R2 = 0.10 for Step 1; DR2 = 0.04 for Step 2 (Ps < 0.01);
than the fathers (M = 28.70; SD = 9.84) and DR2 = 0.03 for Step 3 (Ps < 0.01). *P < 0.01
the children (M = 27.42; SD = 9.46). Paired
samples t-tests showed the statistical signifi-
cance of these differences of means between dental fear levels. As one can see, we
mother–child (t = 4.15; P < 0.01; d.f. = 182) obtained significant positive correlations
and mother–father (t = 3.13; P < 0.01; between father’s and mother’s fear levels, as
d.f. = 182). Although the fathers’ dental fear well as between parents’ and children’s dental
scorings were also higher than their chil- fear scores. Thus, our first hypothesis was
dren’s, these differences were not statistically supported.
significant (t = 1.45; P > 0.05; d.f. = 182). If According to this result, we confirmed that
we consider a total scoring of 45 as a cut- – after controlling for the effects of gender on
point for dental fear, in our sample, 12.6% of dental fear – the mother’s fear scores were a
the mothers, 8.2% of the fathers, and 4.9% significant predictor of the children’s
of the children presented high levels of dental (b = 0.20, P < 0.01) and the father’s
fear. (b = 0.44, P < 0.01) dental fear scores. The
Coherent with previous literature, our father’s dental fear level was also a significant
results also showed differences between predictor of the child’s fear scores (b = 0.25,
schoolboys (M = 24.58, SD = 7.98) and P < 0.01). Table 2 presents the output of the
schoolgirls (M = 30.41, SD = 10.01) as regards multiple regression analyses carried out to
their levels of dental fear, being girls’ DFSS- test a mediating effect between variables. As
DS scores significantly higher (t = 4.48; expected in our second hypothesis, when we
P < 0.01; d.f. = 181). As expected, children’s introduced in the same regression model the
gender is a significant predictor of their levels scores of the mothers and the fathers, only
of dental fear (b = )0.31, P < 0.01). the later remained a significant predictor of
Table 1 shows the correlation coefficients the children’s dental fear levels. Therefore,
between father’s, mother’s, and children’s our second hypothesis was also confirmed,
highlighting a mediating role of the father in
the transmission of dental fear from the
Table 1. Correlations between family members’ dental fear mother to the child.
levels.

Child’s dental fear Father’s dental fear Discussion

Father’s dental fear 0.236* This study was designed to analyse the possi-
Mother’s dental fear 0.227* 0.431*
ble emotional transfer of dental fear among
*P < 0.01 family members and to help to determine its

 2011 The Authors

International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
328 A. Lara, A. Crego & M. Romero-Maroto
transmission mechanisms. Two work hypoth-
eses were set for the analysis: the first one
was approached so as to determine whether
there is a connection between dental fear lev-
els of the mother, the father, and the child.
In particular, it was expected that the more
dental fearful the mother, the father, or the
child is, the more dental fearful the other two
members of this triad would be. The second
one referred to the differential role between
fathers and mothers in terms of transfer of
dental fear to their children.
In line with previous published stud-
ies,2,13,17–20 our analysis confirmed that there
is a direct and significant relationship among
the different levels of dental fear reported by
the family members. This result suggests the
presence of an emotional transfer of dental
fear levels between parents and children.
Other authors, however21–23, have not found
any connection between the levels of dental
fear and the family members. To this respect,
Themessl-Huber13 concluded that the differ-
ences may refer to the various methods for
data collection.
Most of the previous studies have analysed
the behaviour of young children in dental sit-
uation in comparison with the level of mani-
fest anxiety in just one of their parents
(commonly the mother), whereas other
works have studied both parents’ fear lev-
els17–19,24,25. The most relevant contribution
of our study is that we separately analyse the
levels of dental fear for mothers and fathers.
Fathers will play a different role to mothers
as regards child’s dental fear. Concretely,
according to the obtained results, we expect
that children will take their fathers as a key
source of information to decide whether a
dentistry related event may be dangerous or
not, and thus, fathers’ dental fear level will
be a mediator variable in the relationship
between mothers and children’s dental fear
levels. As our regression analyses series have
pointed out, the mothers’ dental fear signifi-
cantly predicts the levels of dental fear of
fathers and children. Fathers’ dental fear pre-
dicts the children’s dental fear, too. Finally,
when the levels of fear of mothers and
fathers are jointly included in a regression
model, only the fathers’ dental fear remains
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
as a significant predictor of the children’s fear.
According to Baron and Kenny’s procedure,
these results provide with support for a medi-
ating role of the fathers’ dental fear on the
relationship between mothers’ and children’s
dental fear.
Just a few articles have included a separate
perspective of dental fear levels for mothers
and fathers23,26,27. Our results are in line with
the conclusions found in those studies.
To this respect, and coherently with our
results, Rantavuori20 concludes that for chil-
dren under the age of 12, fathers’ dental fear
is one of the best indicators of potential den-
tal fear in children. This author reports that
for 9-year-old children – a similar age to our
study sample – fathers’ dental fear is the best
predictor of children’s ‘Fear of dental treat-
ment in general’ and ‘Fear of dental decay’.
This study suggests that both fathers and
mothers play different roles in the onset of
dental anxiety and fear in children according
to children’s age.
Gender is also a key predictor for determin-
ing the level of children’s dental fear,
although we do not focus specifically on this
variable during our analysis. Our results are
coherent with other articles published to this
respect, pointing out a higher incidence of
dental fear among girls7,28.
With regard to the prevalence of dental fear
in children, only 4.9% of children presented
significant levels of dental fear, which con-
firms a low prevalence. Furthermore, this
result is in line with previous literature in this
field that reported prevalence figures varying
from 5% to 20%, with a mean of 11%6.
Although this might be considered as a limi-
tation of our results, the type of analysis that
was carried out (step-by-step hierarchical
multiple regression) depends on the amount
of variability of the dependant variable
(child’s fear) that can be explained by the
influence of the independent (mother’s fear)
and mediating (father’s fear) variables, and it
is not related to the proportion of children
suffering from dental fear.
We must admit, however, that the study
was limited by the use of a convenience (not
representative) sample – composed of stu-
dents of two schools that voluntarily
 2011 The Authors

participated in the study. We should also con-
sider as study’s limitations that our data were
self-reported by participants together with the
possible ‘social desirability’ of their responses
(as for example in the case of children trying
to hide their fears). Finally, although it can
be assumed that individuals in our sample
come from a homogeneous mid-class social
stratum, the possible influence of socio-eco-
nomic factors was not controlled in analyses.
According to both our results and the above
cited study by Rantavuori20, and concerning
dental fear, we should question whether the
role that fathers play in the age range consid-
ered in our study remains stable at different
ages and in particular whether the father’s
role is still relevant with younger children
and decreases its relevance for children older
than the ones included in our sample.
Besides, more research would be needed on
the specific role played by mothers at differ-
ent stages of children’s growth. These develop-
mental issues remain an interesting topic for
future research.
The results of our study may provide fur-
ther information for both dental surgeons
and, especially, dental paediatricians to antici-
pate and prevent dental fear reactions of chil-
dren during consultation. If they are aware of
the fear levels experienced by parents, they
will be able to anticipate to their children’s
levels of fear. Our conclusions allow us to
identify also the father’s role as a key point
for dental fear transmission, or in reverse for
interruption of emotional contagion among
family members. Thus, interventions aiming
to reduce fathers’ dental fear levels (e.g. pro-
viding them with accurate information on
dental treatments, simple relaxation tech-
niques, or changing their possible negative
thoughts and expectancies) may help to miti-
gate or neutralize the spreading of dental fear
to children. When fathers display calm or
other positive emotions (e.g. joy) or verbalize
positive thoughts (e.g. self-efficacy) at the
dentist, it could be useful that professionals
encourage fearful children to pay attention to
their fathers’ behaviour. By doing this, chil-
dren would be exposed to a positive model-
ling and receive reassuring clues on how to
interpret dental situations.
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
Emotional contagion of dental fear to children 329
What this paper adds
• Empirical evidence on the presence of emotional con-
tagion of dental fear among family members.
• An approach to the mechanisms by means of which
dental fear is spread from parents to children.
• Support for the hypothesis of a key role of the father in
the transmission of dental fear from mothers to children.
Why this paper is important to paediatric dentists
• It points out how dental fear is spread into the family,
offering possible ways to short-circuit the transmission
of dental fear from parents to children.
• By knowing parent’s dental fear levels, paediatric den-
tists can anticipate and prevent child’s possible fear or
misbehaviour in dental consultation.
• It provides further information about the role played
by fathers and mothers as regards to the presence of
dental fear in children.
Acknowledgements
The authors wish to thank Colegio Castilla
and Colegio San José (Torrejón de la Calzada,
Madrid, Spain) for participating in this
research.
Conflict of interest
The authors declare no conflict of interest.
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