International Journal of Paediatric Dentistry 1995; 5: 23-28

Children’ s dental anxiety:

influence of personality and intelligence factors
M. TOLEDANO, R. OSORIO, F. S. AGUILERA 8z J. PEGALAJAR
Department of Ergonomics in Dentistry, Universio of Granada, Spain

Summary. Forty children (20 boys and 20 girls) aged 8-16 years with no previous
experience of dental visits were included in the study. Three psychological variables were
determined: anxiety (State-Trait Anxiety Inventory of Children), personality (Eysenck
Personality Questionnaire-Junior) and intelligence (Wechsler Intelligence Scale for
Children). The relationship between personality and intelligence factors and the levels of
anxiety at the beginning of the first dental visit (before treatment) and at the end of the
third visit (after treatment) were determined. There was no significant relationship between
levels of dental anxiety and age. Dental anxiety both before and after treatment was higher
among the girls than among the boys. Children with high intelligence quotients showed
less dental anxiety at their first dental visit. There was no relationship between the
children’s anxiety and their own personality variables.

Introduction unpleasant dental experience [ 14-17]. Dental anxiety

can also develop from contact with other persons who
Dentists must consider not only the total physical
have had unpleasant dental experiences [ 18-20].
condition of their patients but also their psychological
Fantasy of dental situations appears to be very
and emotional state [ 11. For many years dental anxiety
important for the fearful patient [21]. In addition, one
and fear of dental treatment has been recognized as a
of the most important factors in explaining children’s
source of problems in the management of child dental
dental anxiety is their level of general anxiety [22,23].
patients [2-4].
A study of children’sindividual characteGsticsmay
The main problem encountered in studying anxiety
help in the understanding of their dental anxiety, their
lies in the quantification of this emotion [5]. The most
problems and special needs [ 11,24,25]. The aim of the
consistentlyemployed measurements are rating scales
present study was to examine children’s individual
determined by the subject or by an observer [6-91.
characteristics (age, sex, intelligence quotient and
Psychological measures, such as polygraphic record-
personality variables) and to assess the association
ings of heart rate, hand and face temperature, and
between these factors and their dental anxiety levels.
galvanic skin response can be used, but the practical
usefulness of these procedures is limited because
obtrusive measurements are required and evoke an Methods
increase in children’s anxiety, which complicates the
The subjects consisted of 40 children of middle-class
results [lo].
families from the metropolitan area of Granada. The
When treating an anxious child, it is important for
subjects were randomly selected from patients attend-
the dentist to understand the reason for the child’s
ing the School of Dentistry, University of Granada.
nervousness [ 11,121. Previous research has identified
The children had no previous experience of dental
several factors which may’ have effects on dental
visits and had at least two carious lesions in molars.
anxiety [13], the most frequent being a painful or
Their levels of general or dental anxiety were not
known and they did not have any medical or
Correspondence: Dr M. Toledano, Avda. Fuerzas Armadas n’l, psychological problems. The purpose of the study was
1°B, 18014 Granada, Spain. explained to the parents and their consent was
0 1995 BSPD and IAPD. International Journal of Paediatric Dentistry 5: 1 23
24 M. Toledano et al.

obtained. Personal data (name, age, sex, address) were and Mann-Whitney) were used for comparisons and
noted. Spearman’s rank correlation was used to examine the
On their first visit all the children received a full relationship between anxiety, psychological factors,
extraoral and intraoral examination and a dental age and sex. Analyses were carried out using the
prophylaxis, and two bitewing radiographs were +
statistical package SPSSPC V.4.0 1990 (SPSS
taken. On the second and third visits an amalgam Inc., Chicago) [31].
restoration was placed in selected molar teeth. Local
anaesthesia and rubber dam were used.
Three psychological variables were studied: anxi-
Results
ety, personality and intelligence. The age distribution of the boys and girls is given
General and dental anxiety were assessed using the in Table 1. The mean age of the boys was 10.09
State-Trait Anxiety Inventory of Children [26] (SD 2-30), of the girls 10.11 (SD 1-40) and of the
(STAIC). The STAIC is used to measure two distinct total sample 10.10 (SD 1.93).
anxiety concepts: A-state, the transitory emotional
condition characterized by subjective, consciously- Table 1. Age and sex distribution of the 40 subjects.
perceived feelings of apprehension, and A-trait, the
No. of No. of
relatively stable anxiety-proneness of an individual. Age boys girls Total
All the tests were conducted by the same investigator
(F.S.A.) in a quiet room separate from the paedodontic 8-9 6 3 9
9-10 6 3 9
clinic and the waiting room. The children were asked lcl 2 7 9
to complete the scales twice: at their first visit (before 11-12 1 4 5
being examined), and at the end of the third visit when 12-13 0 2 2
dental treatment was finished. About 15 minutes were 13-14 3 1 4
14-15 1 0 1
needed to complete the test. This instrument of known 15-16 1 0 1
validity and reliability has been used in previous
investigations of dental anxiety [7,27,28].
The children’s personality was studied using the The data in Table 2 show the State-Anxiety Scores
Eysenck Personality Questionnaire-Junior (EPQ-J) (i.e. dental anxiety) at the first visit (before treatment)
[29]. This instrument consists of 81 items to evaluate and at the third visit (after treatment); there was no
neuroticism (or emotionality),extraversion, psychoti- statistically significant relationship between anxiety
cism and sincerity.This survey was conducted at each and age. Some differences in median anxiety scores
child’s second visit, just before dental treatment can be observedbetween some age groups but they did
commenced, in the same quiet room and by the same not reach statistical significance. The State-Anxiety
investigator (F.S.A.) who conducted the STAIC. scores for the girls group, both before and after
About 20 minutes were required for this survey. treatment, were significantly higher (P < 0-05and
The children’s intelligence was assessed using the P < 0.01, respectively) than in the boys group, and it
Wechsler Intelligence Scale for Children (WISC) is important to emphasize that there was no difference
[30]. This scale is an instrumentfor evaluating general between the mean ages of the boys and girls. For both
intelligence, denoting its components: verbal, manip- boys and girls, the anxiety scores were significantly
ulating and total intelligence quotient. The tests were higher (P < 0.001) before treatment than after treat-
done in the same room by a psychologist (J.P.), on ment.
visits especially arranged for the purpose after each None of the personality factors (emotionality,
child’s third dental visit. The minimum time allowed extravertion, psychoticism and sincerity), nor the
for the test was 1 hour and 30 minutes. Intelligence Quotient, were associated with the age or
sex of the subjects (Table 3). In addition, none of the
personality factors was associated with anxiety levels
Statistical analysis
before treatment. However, there was a negative
Median and quartile deviation were used as descrip- relationship between the total intelligence quotient
tive statistics except for age, which was treated as a and State (dental) anxiety; children with high intelli-
quantitative variable using mean and standard devi- gence quotients showed less anxiety at their first
ation. Non-parametric tests (Wilcoxon’s paired rank dental visit (P< 0.02).
0 1995 BSPD and IAPD, International Journal of Paediarric Dentistry 5: 1
 Children’s dental anxiety 25

Table 2. Median state-anxiety scores (percentiles)before and after treatment.

State-anxiety scores

Boys Girls

Before After Before After

8-9 32.50 6.50 50.00 5.00

9-10 20.00 2.00 45.50 47-50
10-1 1 62.50 6.50 50.00 45.00
11-12 60.00 3.50 80.00 30.00
12-13 - - 56.00 9.50
13-14 4.00 400 5.00 2.00
14-15 75.00 4.00 - -
15-16 20.00 2.00 - -
All 30.00 4.50 50.00 15.00
Difference
25-75 percentiles 48.00 6.50 70.50 41.00

Table 3. Spearman’s rank correlation coefficients (rs)between intelligence quotient, personality factors, age, sex
and anxiety before treatment.
~~

Age Sex State anxiety Trait anxiety

Emotionality 0.19, P>O.lO 0.25, P > 0.10 0.23, P>O.lO 0.32, P > 0.05
Extraversion 0.07,P > 0.50 0.21, P>O.lO 0.12, P>0*20 0.09,P>0*50
Psychoticism 0.16, P > 0.20 0.06, P > 0.50 0.05, P > 0.50 0.06, P > 0.50
Sincerity 0.08, P > 0.50 0.04, P > 0.50 0.31, P>O.O5 0.22, P > 0.20
I.Q. 0.26, P>O.lO 0.22, P > 0.10 0.46, P < 0.02 0.03, P > 0.50

Discussion may react to a greater degree than girls to external

The relationship between anxiety in dental and
non-dental settings is important for determining the
nature of a child’s dental fear. Previous studies have
revealed that dental anxiety may reflect more general
anxiety, rather than fear learned in response to a
specific situation [32]. Brown et al. [21] also found
that the most important factor explaining children’s
dental anxiety was their level of general anxiety.
Four types of measures relevant to the study of
anxiety have been extensively employed: direct
ratings of behaviour, self-report measures, physio-
logical measures and projective tests. We employed
self-report measures but it is well known that each of
the four different types of measure appears to
represent a useful and valid means of studying anxiety
in the child [32].
As reported in other studies [3,21,32-351, anxiety
appeared to be higher in the girls in our study. Winer
[32] reported also that sex differences increase with
age. Liddell [36] and Toledano [35] suggested that
these differences may indicate a tendency for girls to
be more influenced by internal factors, whereas boys
0 1995 BSPD and IAPD, International Journal of Paediarric Dentisfry 5 1
stresses.
Social class variables have not been consistently
related to fearful or anxious behaviour in previous
studies. The few studies of social class differences
have presented conflicting results: thus Frankl et al.
[37], Winer [32], Bedi [35] andMilgrom [16]reported
no differences, although differences were found by
Wright & Alpern [38]. To avoid any kind of influence
we included in our study only children from the
middle socio-economic stratum.
Dental anxiety was higher in the children before
than after treatment. DemiriSz [l], and Brown &
Wright [39] also found that dental anxiety was
higher in children with no previous dental visits. This
anxiety in the absence of any dental experience
may have several sources, one of which could
be exposure to other children and relatives with
unpleasant dental experiences [18,19,40-42]. This
could be a reason for not permitting parents to enter
the dental surgery during treatment, especially be-
cause there is evidence that some of the strategiesused
by the parent to calm their children may have the
opposite effect [36,43]. Fear of unknown situations
26 M. Toledano et al.
may also have predisposed the children to judge the
dental situation as adversive. After treatment the
child’s anxiety was only dependent on hisher own
dental experience.
There was no association between age and anxiety,
which supports the findings of Bailey [43], Howitt
[44] and Spr & Kominek [45]. Nevertheless, differ-
ences in reaction to dental treatment according to age
have been shown previously [9,21]. When studies
reporting correlationaldata or studies reporting means
and frequencies are examined, there is considerable
evidence that positive behaviour increases with age,
and some evidence that there are no anxiety changes
with age [32]. There are certain dangers in simply
presenting correlations between age and behaviour
[46] because it could only indicate a decrease with age
in the tendency to admit to being afraid [43], or an
increase in self-control but not a decrease of anxiety.
With age there is also an increase in dental experience,
and dental anxiety may well decrease with repeated
exposure to dental procedures [39]. Theoretically, the
age changes suggest the possibility of substantial
changes in processes underlying the experiencing and
the control of fearful behaviour, but the change with
age is not easily explained and leaves much room for
experimental analysis.
The present study has indicated that there is
no association between personality variables and
dental anxiety levels. Lautch [47] found that
fearful patients scored higher on Eysenck’s neur-
oticism scale and lower on the extraversion scale
than non-fearful controls, but that all fearful
subjects had reported at least one traumatic dental
experience.
There have been few studies correlating intel-
ligence quotient with dental behaviour. We found
a significant correlation between IQ and anxiety
at the first dental visit. Rud & Kisling [48] re-
ported that children with lower IQs showed
more fearful behaviour. It therefore seems pos-
sible that a relationship exists between IQ and dental
fears, but this hypothesis must undergo closer
examination.
La peur du dentiste chez l’enfant: influence de
l’intelligence et de la personnalit6
Resume. Quarante enfants (20 gargons et vingt filles)
AgCs de 8-16 ans, qui n’avaient jamais eu de soins
dentaires, ont CtC CtudiCs. Trois variables psycho-
logiques ont CtC dCterminCes i l’aide de tests: I’anxiCtC
(inventaire des sympttimes d’anxiCtC chez l’enfant),
la personnalitk (questionnaire d’Eysenck de per-
sonnalitk pour jeunes) et intelligence (Cchelle
d’intelligence de Wechsler pour enfants). Les rela-
tions entre la personnalitk et l’intelligence et le niveau
d’anxittC, au debut de la premikre consultation (avant
traitement) et i la fin de la troisi&meconsultation
(aprks traitement) on CtC notCes. I1 n’y avait pas de
relation significativeentre le niveau d’anxiCtC et l’ige.
L’anxiCtC dentaire, avant et apr& traitement,Ctait plus
ClevCe chez les filles que chez les gargons. Les enfants,
dont le quotient intellectuel Ctait ClevC, souffraient
moins d’anxiCtC dentaire lors de la premikre consul-
tation. I1 n’y avait pas de relation significative entre
1’anxiCtC des enfants et les variables de leur person-
nalitC.
Kinder Angst vor den Zahnartzt: Der Einfluss der
Intelligenz und Personalitiit
Zusammenfassung.Anhand von allgemein anerkan-
nten Instrumenten wurden Kinder (20 Jungen und 20
Madchen) im Alter zwischen 8 und 16 Jahren
untersucht, die zuvor noch keine zahniirztliche Praxis
besucht hatten. Es wurden die folgenden psycholo-
gischen Variablen analisiert: Angstlichkeit (Test
STAIC), Personlichkeit (Test EPQ-J) und Intelligenz
(Test WISC). Zwischen diesen psychologischen Fac-
toren und der Auspragung der Angstlichkeit wurde
eine Beziehung vor und nach unterschiedliechen
zahniirztlichen Behandlungen hergestellt. Es besteht
keine Beziehung zwischen der Auspragung der
hgstliichekeit und dem Alter. Offensichtlich geben
Kinder mit hohem Intelligenzkoefizient weniger
hgstlichkeit bei ihrem ersten zahniirztlichen Besuch
Zu erkennen als diejenigen mit niedrigem Koefizient.
Die Angslichkeit vor dem Zahnarzt ist in der Gruppe
der Madchen hoher ausgepragt als bei den Jungen. Es
kann keine Beziehung hergestellt werden zwischen
der Angstglichkeit der Kinder und der Variablen, die
die eigene Personlichkeit bestimmen.
Ansiedad dental en niiios: influenciade 10s factores
personalidad e inteligencia
Resumen. Se estudiaron 40 niiios (20 varones y 20
hembras) de 8-16 aiios de adad sin visitas previas al
consultorio dental. Se analizaron las siguientes vari-
ables psicol6gicas: ansiedad (test STAIC: State-Trait
Anxiety Inventory of Children), personalidad (test
EPQ-J: Eysenck Personality Questionnaire-Junior),
0 1995 BSPD and IAPD, International Journal of Paediatrii Dentistry 5: 1

e inteligencia (test de WISC: Wechsler Intelligence
Scale for Children). No se detect6 relacidn entre estos
factores psicoldgicos y 10s niveles de ansiedad y la
edad. La ansiedad fue mayor en las niiias que en 10s
niiios. Los niiios con alto coeficiente intelectual
manifestaron menos ansiedad en su primera visia
dental que aquellos con dicho coeficiente m8s bajo.
No se encontrd relacidn entre la ansiedad de 10s niiios
y la variables que determinan su propia personalidad.
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