Received: 27 June 2019

| Revised: 21 August 2019

| Accepted: 7 November 2019

DOI: 10.1111/ipd.12595

ORIGINAL ARTICLE

Stimuli involved in dental anxiety: What are patients afraid of?:

A descriptive study

Tania Vanhee1 | Sandrine Mourali1 | Peter Bottenberg2 | Wolfgang Jacquet2 |

Astrid Vanden Abbeele1

1
Department of Paediatric Dentistry,
Université Libre de Bruxelles, Brussels,
Belgium
2
Oral Health Research Group, Vrije
Universiteit Brussel, Brussels, Belgium
Correspondence
Tania Vanhee, Department of Paediatric
Dentistry, Université Libre de Bruxelles, CP
622 808 Route de Lennik, 1070 Brussels,
Belgium.
Email: tanivhee@ulb.ac.be
Abstract
Background: Dental anxiety is a psychological response inducing aversion follow-
ing a dental ill-defined stimulus, non-imminent and perceived as potentially danger-
ous. It is better to intervene during childhood than to resolve in adulthood when
dental anxiety is more settled. Aim: The purpose of this study is to determine the
nature of dental anxiety-provoking stimuli in young patients.
Design: A questionnaire was submitted to 566 children between 3 to 18 years in
health institutions and schools in Brussels, Belgium. The items were divided into
3 groups: environment (ENV), local anaesthesia (LA), and intervention (INT) and
summarized through averaging per group. Descriptive analysis and non-parametric
testing were combined with logistic regression after discretization, above mild, for
the group averages.
Results: About 7.2% of the respondents expressed high to severe dental anxiety.
Several items presented a clear bimodal distribution dividing the population in fear-
less and fearing patients, for example, sight and feel of the syringe, sight and taste
of blood and extraction. Others presented with a gradually lower incidence with in-
creasing fear level. Fear for the environment was generally low. Gender and ethnic
origin contribute significantly to the prediction of fear caused by LA. For fear caused
by INT, first the place of questioning enters the models, thereafter follow: negative
experience, frequency of dental visit, and gender (P < .05).
Conclusions: While the dental environment is in general not causing fear, the in-
vasive part of the anaesthesia and the invasive dental procedures are involved. Fear
seems to be related to culture, previous experience, and gender.

KEYWORDS
child, dental anxiety, etiology, pediatric dentistry, stimuli

1 | IN TRO D U C T ION
If the fear of the dentist is a normal emotional reaction of
uneasiness to a stressful situation in a dental care, dental
anxiety represents a superior state of the negative reaction.
Anxiety is excessive and unreasonable with respect to the
situation. These two notions are however regularly confused
in the literature.1 The list of psychiatric disorders, DSM
V, distinguishes between fear and phobia, considering the
latter as pathological. It is an anxiety disorder where the
phobogenic stimulus is either avoided or endured with in-
tense distress. The phobia of the dentist is thus considered

276 | © 2019 BSPD, IAPD and John Wiley & Sons A/S. wileyonlinelibrary.com/journal/ipd Int J Paediatr Dent. 2020;30:276–285.
Published by John Wiley & Sons Ltd

VANHEE et al.
as a specific phobia.2 Dental anxiety (DA), a psycholog-
ical response to aversion following an ill-defined or not
immediately present stimulus perceived as potentially
dangerous, predisposes to a negative experience in the of-
fice.3,4 The main effects of the dentist's fear are poor oral
health,5 the maintenance of a vicious circle of avoidance
to make appointments, and/or regular non-presentation
at appointments. Visits occur only in case of pain or sig-
nificant problems, leading to increased anxiety. 6 General
signs are described as muscle tension, increased heart and
breathing rate, unusual sweating, and abdominal cramps.7
In reaction to the patient, the dentist experiences elevated
stress levels when treating an anxious or phobic patient.8
Fear of the dentist is one of the principal causes of irregular
visits to the dentist together with the lack of time, cost, and
accessibility of the dental office.9 The prevalence of me-
dium to high dental anxiety ranges from 13.1% to 19.8% of
the population and dental phobia from 3% to 7.1%.10 Some
groups of patients are at higher risk for dental anxiety, such
as those with psychological disorders11 such as anxiety or
depression12 or those with a history of sexually abuse.13,14
The origins of dental anxiety are numerous. The two most
cited in the literature report a family member with fear of
the dentist and/or a bad experience at the dentist.15-17 These
findings corroborate the idea that the aetiology of anxiety
about dental care is exogenously, that is fear is conditioned
by a painful stimulus or its description. This paradigm does
not however provide a general valid explanation. Indeed,
many patients who apprehend the visit to the dentist have no
phobic parent, nor suffered trauma in a previous consulta-
tion. In addition, many individuals who remember a negative
dentist experience do not develop any phobia.18 In addition,
it is shown that dentophobic persons have a high prevalence
for other fears (suffocation, height) as well as specific traits
of temperament (anxiety, timidity).19,20 Despite a significant
improvement in dental techniques, the prevalence of dentist
fear has been constant since the 1950s.21 Therefore, the fear
of the dentist has a multifactorial aetiology where the en-
dogenous component is important.18,21
Many solutions exist to manage the fear of the dentist:
relaxation, hypnosis, group therapy, management by a spe-
cialist, benzodiazepines, short-term antidepressant treat-
ment, and conscious sedation. Behavioural therapies seem
to show the best results in the long term.21-23 The fear of
the dentist seems however to be more settled in adulthood
than during childhood. Therefore, it would be better to in-
tervene in the fear of the dentist during childhood than in
adulthood.24
Unlike many articles aiming to present a scale measur-
ing the intensity of dental anxiety,25-27 we deliberately chose
another approach. Indeed, rather than trying to answer the
questions Dental anxiety—"why?" or "how?”, we attempted
to resolve: Dental anxiety—“of what?".
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   277
Why this paper is important to paediatric
dentists?
• First analyse about dental anxiety stimuli ex-
pressed by children with a comparison between
the different age groups.
• Better understanding of the important points to
improve in paediatric dental practice by the statis-
tic analyse with logistic regression model.
• More attentions by paediatric dentists about the
place of the anxiety during the intervention and
not only during the local anaesthesia.
The purpose of this study is to provide evidence to
determine with an adapted questionnaire the nature of
anxiety-provoking stimuli in young patients in paediatric
dentistry.
2 | M ATERIAL AND M ETHOD S
2.1 | Study design
The study consisted of a self-administered questionnaire
(Figure 1) completed both in an university hospital for chil-
dren (HUDERF, ULB, Brussels, n = 416) and in two Brussels
Schools (namely the ISND and the STEYLS School, after
obtaining the authorization from the principal and teachers,
n = 140).
The participants were of different age categories, being 3
to 6 years old (preschool), from 7 to 12 years (the transitional
age) and from 13 to 18 years (adolescence).
2.2 | Questionnaire
2.2.1 | Items choice
The objective is to resolve: Dental anxiety—“of what?".
Therefore, no attempt will be made hereafter to develop a psy-
chometric measurement tool. We however used the different
existing validated questionnaires to group the items to be able
to answer our question in the most exhaustive way possible.
The items included in the questionnaires listed in this
paper were selected according to their relevance to the theme
of this study and their references in literature.28 Our very own
form is based on the following questionnaires: Corah's DAS:
Corah's Dental Anxiety Scale29; MDAS: Modified Dental
Anxiety Scale30; DFS: Dental Fear Survey31; CFSS-DS3:
Children Fear Survey Schedule—Dental Subscale; and DAxI:
Dental Anxiety Inventory.32
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278    VANHEE et al.

1. 2. 3. 4. 5. FIGURE 1 Questionnaire for children

Not scared at all A little scared Fairly scared Very scared Terrified
1 Are you afraid of the dentist? 1 2 3 4 5
Among the items below, tell us about your fear. Just “how much” are you afraid?
2 The day before the appointment? 1 2 3 4 5
3 When you are in the waiting room? 1 2 3 4 5
4 When you sit in the chair? 1 2 3 4 5
5 The smell of products they put in your mouth? 1 2 3 4 5
6 The taste of products they put in your mouth? 1 2 3 4 5
7 The smell of the dental office? 1 2 3 4 5
8 Seeing the syringe 1 2 3 4 5
9 Feeling the needle injected? 1 2 3 4 5
10 The sensation induced by anesthesia (tingling, prickling) 1 2 3 4 5
11 The way you feel when anesthesia wears off 1 2 3 4 5
12 Seeing the dental instruments (drill/contra-angle)? 1 2 3 4 5
13 Feeling the vibrations for the dental drill/contra-angle? 1 2 3 4 5
14 Hearing the dental drill/ contra-angle? 1 2 3 4 5
15 Seeing water suction 1 2 3 4 5
16 Feeling water suction 1 2 3 4 5
17 Seeing the other dental instruments (probe, mirror, etc.) 1 2 3 4 5
18 Feeling the other dental instruments (probe, mirror, etc.) 1 2 3 4 5
19 To have light in the face? 1 2 3 4 5
20 Lying back/down in the dentist’s chair? 1 2 3 4 5
21 Not being able to speak or express yourself? 1 2 3 4 5
22 To have something in your mouth/ the work that’s being done 1 2 3 4 5
in your mouth?
23 b h ? dam? (the green or blue piece of plastic around the tooth)
The rubber 1 2 3 4 5
24 The dentist’s clothing? (gloves, mask, blouse) 1 2 3 4 5
25 Seeing blood? 1 2 3 4 5
26 The taste of blood? 1 2 3 4 5
27 To be told that a tooth needs to be extracted? 1 2 3 4 5
28 To be told that you have a cavity? 1 2 3 4 5
29 Not being able to see what is being done? 1 2 3 4 5
30 Being admonished (for instance because you didn’t brush your 1 2 3 4 5
teeth correctly or because you don’t open your mouth widely
31 Have you ever had a bad experience at the dentist? (For Never 1x >1x
instance because he hurt you a lot or yelled at you?)
32 Have you had any dental information sessions (this means that Yes No
someone explained to you how to brush your teeth, explained to you
what decays are…)
33 How often do you come to the dentist? <1x/year 1x/ year >1x/ year
34 Do you have cavities, fillings or missing teeth? 0 1-3 4-6 >6

As part of our study, the questionnaire was written and
submitted to participants in French. For this article, the
English translation of the questionnaire was performed by an
independent professional translator.
2.2.2 | Evaluation scale
2.3 | Ethical considerations
Ethical approval was obtained when the study protocol was
reviewed and agreed by the ULB medical faculty/HUDERF
ethical committee (number CEH n°2/14). Written consent
from the parents and the children was collected just before
the questionnaire administration.

For teenagers, we used a Likert scale with levels: “not at all” =

1, “mild” = 2, “moderate” = 3, “high” = 4, and “Severe” = 5. As
far as children are concerned, the difficulty lies in their cognitive
interpretation of the words and the integration of their semantic
nuances. Therefore, the measures used above were adapted from
the “Wong-Baker” scale which uses emoticons, each expressing
a specific emotion.33 This scale basically presented a visual ana-
logue scale from 1 to 6 faces in order to measure the intensity of
pain and was redesigned for the purposes of this study.
2.4 | Statistical analysis
A descriptive analysis was performed on item level and ex-
ploratory non-parametric testing throughout the analysis at a
nominal significance level of α = 0.05 (Chi-square—Mann-
Whitney U, and Kruskal–Wallis). For each of the aspects
(environment, anaesthesia, and intervention), the average of
all questions answered was calculated. Thus, the calculated

VANHEE et al.
aspects were discretized. A patient was considered to have a
substantial fear if average was superior to two, correspond-
ing to a “mild” fear. A stepwise forward sequential logistic
regression modelling approach was adopted with a P-value
for inclusion equal to .05 and a P-value for exclusion of .10.
The following predictors were used: gender, negative experi-
ence (at least one), ethnic origin, history of caries, frequency
of visits, and correcting for whether or not the questionnaire
was administered at the hospital or a school.
Statistical analysis was performed using IBM SPSS v.
25.0 (SPSS Inc, Armonk, NY).
3 | R E S U LTS
A total of 556 children participated in this study, 47.50%
boys (n = 264) and 52.50% girls (n = 292). About 19.60% of
the study population is between 3 and 6 years old (n = 109),
48.00% between 7 and 12 years old (n = 267), and 32.40%
between 13 and 18 years old (n = 180). Age and gender
distribution of the sample is comparable (chi-square test,
P = .085) to the Belgian population for the same age range.34
All independent variables are described in Table 1.
More than half of the children (56.10%) expressed no fear
to visit a dentist, 36.70% a mild to moderate fear, and 7.20%
a high to severe fear.
The different items of the questionnaire were ranked from
the greatest degree of fear reported by the subjects to the
smallest in Table 2.
Table 2 shows the results obtained for each item. The most
anxiety-inducing elements relate to invasive procedures: the
sight of a syringe and the evocation of extraction instil fear
among 70% of patients. The smell, the sight, and even the
sound of the drill induce fear in approximately one out of two
patients. Patients experience a similar percentage of anxiety
in the waiting room or in the dentist's chair.
Another important issue is communication and relation-
ship with the dentist: not seeing or knowing what is happening
as well as the inability to express emotions brings two out of
five patients to experience fear. In the same way, a moralizing
and authoritarian practitioner will not improve these results.
Conversely, the aspirations, the smell of the dental office, the
light, lying down, the rubber dam, and the clothing of the dentist
(gloves, mask and laboratory coat) may cause but minor anxiety.
3.1 | Analysis by categories
In Table 2, the different items are divided into 3 groups:
environment (ENV), local anaesthesia (LA), and interven-
tion (INT). In order to be able to determine the independent
variables that have a statistically significant relationship with
the different situations, a logistic regression model has been
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   279
developed. To carry out this analysis, the choice was made to
determine a cut-off, above mild, in the responses to the ques-
tionnaire between the absence of fear and the presence of fear.
In this bimodal analysis, no environmental criterion showed
statistical significance contrary to the other two categories.
Indeed, for the fear caused by the environment, none of the
contributions of the independent variables was significant. The
p-values ranged from 0.086 to 0.997. Note that the incidence
rate fear by environment is rather low (17.1%). Gender and
ethnic origin are contributing to the prediction of fear caused
by the anaesthesia—see Table 3. For fear caused by the in-
tervention itself, first the place where the questionnaire was
administered enters the models, thereafter follow: negative ex-
perience, frequency of dental visit, and gender—see Table 4.
3.2 | Stratified analysis according to the
age groups
Between 21.10% and 41.60% of young patients reported mild
to moderate fear. With regard to the level of dental anxiety,
they reported 11.96% for children aged 3 to 6 years, 6.40%
for children 7 to 12 years old and 5.50% for teenagers to have
high to severe fear.
The distribution of fear levels according to the age groups
is recorded in Figure 2.
The estimated dichotomy for category analysis with a cut-
off at two was retained for analysis by age group. Children
aged 3 to 6 years (n = 109) had the highest percentage of
fear for the items "Seeying syringe" (54.1%) and "Feeling
injection" (43.1%). The other most cited items are "Tooth
extraction" (34.9%), "Seeing blood" (34.8%), and "Being ad-
monished" (32.1%).
Children aged 7 to 12 years (n = 267) had the highest per-
centage of fear for the items "Seeying syringe" (54.5%) and
"Tooth extraction" (51.7%). The other most cited items are
"Feeling injection" (50.6%), "Told that cavity" (32.6%), and
"Being admonished" (30.0%).
Children aged 13 to 17 (n = 180) had the highest per-
centage of fear for the items "Tooth extraction" (59.9%) and
"Feeling injection" (53.4%). The other most cited items are
"Seeying syringe" (49.0%), "Told that cavity" (38.9%), and
"Drill vibrations" (37.2%).
The most frequent missing data are for the three age
groups: "Rubber dam" (88.1%, 74.2%, and 66.7%), "Local
anaesthesia" (33.9%, 18.4%, and 13.3%), and “Mouth wake
up” (33.9%, 18.0%, and 13.9%)—see Table 5.
4 | DISCUSSION
Our study allowed us to analyse three points of view. The
first corresponds to a population sample comparable to the
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280    VANHEE et al.

TABLE 1 Distribution of independent variables Belgian population of the same period.34 We can consider
n % that the conclusions of our study can represent a descrip-
tion of the causes of dental anxiety felt by children from 3 to
Population 556 100
18 years old. According to the description obtained in Table
Gender
2, this allowed us to divide the items of the questionnaire
M 264 47.50 into three categories and thus to search by logistic regression
F 292 52.50 analysis for the aetiology of dental anxiety in our sample: in-
Age tervention, local anaesthesia, and environment. Dental phobia
3-6 y 109 19.60 was listed in 2013 by the American Psychiatric Association
7-12 y 267 48.00 in its DSM 5 as a specific phobia and more specifically in
13-18 y 180 32.40 the blood-injection-injury (BII) category.35 The link between
Hospital
BII, nausea patients, and dental anxiety was illustrated by
Almoznino in 2016. 36
Yes 416 74.,80
A 5-year-old is probably however not afraid for the same
No 140 25.20
reasons as a 15-year-old. This is why we chose to focus our
Negative experience third point of view on analysis by age group.
Never 396 71.20 From Table 2 and according to the calculated dichotomy
One 85 15.30 for logistic regression analysis, an analysis by age group was
More than one 30 5.40 performed. Two points of view are to be highlighted: the
Preoperative informations evolution of the items presenting a high percentage of den-
Missing 39 7.00 tal anxiety according to the age group and those with a high
Yes 263 47.30
quantity of missing data.
Missing data on the questionnaire may mean that the
No 254 45.70
patient did not understand or feel concerned by the ques-
Visit frequency
tion. The majority of items have a percentage of missing
missing 24 4.30
data from 0% to 7%. 2 items however have a percentage
<1/year 89 16.00 of missing data at 20%: they concern questions about the
1/year 163 29.30 sensations of local anaesthesia when the mouth falls asleep
>1/year 280 50.40 and when the mouth wakes up. The idea of having a local
n % anaesthesia is one of the fears most often spontaneously
expressed by patients in our practice. In our study, this is
Birth location
the category expressed at a high percentage regardless of
Missing 28 5.00
the age of the child, which corresponds to the literature.
Eastern Europe 18 3.20 The high percentages of missing data can be explained by
Western Europe 475 85.40 the fact that patients probably never had local anaesthesia.
North Africa 11 2.00 This finding is all the more plausible for the rubber dam.
South Africa 15 2.70 Indeed, the item concerning the rubber dam shows a per-
Other 9 1.60 centage of missing data at 75%. Very few patients have ever
Ethnic origin had a dental dam and even more before 18 years old. This
dental surgical field system, which has been available for
Missing 11 2.00
more than 150 years, offers considerable dental benefits in
Eastern Europe 63 11.30
terms of comfort for the practitioner and the patient, both
Western Europe 168 30.20
in terms of technique and feeling during dental treatment.37
North Africa 190 34.20 This tool is underused by dentists.38 It should be however
Subsaharian Africa 77 13.80 kept in mind that, in our study, 41% of patients report hav-
Other 47 8.50 ing a dmft/ DMFT of 0. The 20% of missing data for items
DMFT/dmft relating to LA can then easily be explained: no caries so
Missing 30 5.40 no AL. The 75% of missing data for the rubber dam would
0 228 41.00 also be explained by this hypothesis completed by its un-
1-3 199 35.80
derutilization in general in dentistry.
Regarding the highest percentages in the responses to
4-6 65 11.70
the questionnaire, we observe a change according to the age
>6 34 6.10
group: in the 3 to 6 years; it is the representation of the acts
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VANHEE et al.    281

TABLE 2 Distribution of fear items and their group: environment (ENV), anaesthesia (LA), and intervention (INT)

Items Missing (n) Not at all mild/moderate high/severe All Fears Category
Seeing syringe 3% (18) 25% 36% 36% 72% LA
Feeling injection 5% (28) 26% 34% 35% 69% LA
Tooth extraction 4% (20) 28% 29% 39% 68% INT
Drill vibrations 7% (41) 38% 35% 19% 54% INT
Told that Cavity 4% (23) 43% 33% 20% 53% INT
Seeing drill 3% (18) 45% 34% 17% 52% INT
Feeling instruments 3% (17) 50% 35% 12% 47% INT
Dentist's chair 0% (1) 54% 36% 10% 46% ENV
Seeing blood 5% (26) 50% 26% 20% 46% INT
Not being able to see 3% (19) 51% 31% 15% 46% INT
Taste blood 6% (32) 52% 25% 17% 42% INT
Being admonished 5% (28) 53% 26% 16% 42% ENV
Waiting room 0% (0) 58% 34% 8% 42% ENV
Something in mouth 3% (17) 55% 32% 10% 42% INT
Hearing drill 4% (20) 57% 27% 13% 40% INT
Not being able to talk 3% (16) 58% 29% 10% 39% INT
Local anaesthesia 20% (110) 42% 27% 11% 38% LA
Seeing instruments 2% (12) 61% 26% 11% 37% INT
Day before 0% (0) 64% 29% 8% 37% ENV
Smell products 4% (21) 64% 23% 9% 32% INT
Taste 4% (22) 67% 21% 8% 29% INT
Feeling water suction 5% (26) 72% 19% 4% 23% INT
Mouth wake up 20% (110) 58% 17% 5% 22% LA
Light in the face 3% (14) 76% 18% 4% 22% ENV
Smell dental office 2% (9) 77% 17% 4% 22% ENV
Seeing saliva ejector 4% (24) 77% 16% 3% 19% INT
Position 3% (14) 82% 13% 4% 16% ENV
Clothes 3% (19) 84% 9% 4% 13% ENV
Rubber dam 75% nn 15% 8% 3% 11% INT

TABLE 3 Logistic regression fear of the anaesthesia

Nagelkerke R
−2 Log likelihood Cox & Snell R Square Square
VALUE 0.036 0.049
B SE Wald df Sig. Exp(B)
Gender
Boy 0.53 0.18 8.71 1 0.00 1.70
Ethnic origin
Other 0.00 0.00 12.11 5 0.03 0.00
Eastern Europe −0.02 0.70 0.00 1 0.97 0.98
Western Europe 0.05 0.40 0.01 1 0.91 1.05
North Africa 0.59 0.34 3.00 1 0.08 1.80
Africa Subsahara 0.75 0.34 4.97 1 0.03 2.12
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282    VANHEE et al.

TABLE 4 Logistic regression fear of the intervention

Nagelkerke R
-2 Log likelihood Cox & Snell R Square Square
VALUE 0.052 0.071
B SE Wald df Sig. Exp(B)
Gender
Boy 0.39 0.19 4.33 1 0.04 1.47
Negative experience
Never −1.03 0.57 3,27 1 0.07 0.36
One time −1.03 0.40 6.64 1 0.01 0.36
More than one time −0.54 0.44 1.47 1 0.23 0.58
Frequency of visits
Less than one per year 0.29 0.58 0.26 1 0.61 1.34
One per year 0.90 0.27 11.07 1 0.00 2.46
More than one per year 0.45 0.21 4.50 1 0.03 1.57
Place of questioning
Hospital 0.67 0.24 7.97 1 0.00 1.95

FIGURE 2 Distribution of fear levels according the age groups

which frighten them more than the act in itself: see the sy-
ringe, see blood, or be admonished are among the most cited
items. In older children, from 7 to 12 years of age, there is an
evolution: from pure representation, one passes to a mixture
with sensations probably due to their own experience. Items
concerning tooth extraction or caries appear. It is in adoles-
cence that the intervention takes the most important place
in relation to the items of local anaesthesia. It will then be
necessary to be particularly vigilant, as a paediatric dentist,
to adapt our care according to this evolution. This evolution
can also be observed if one compares the different studies
made on the subject but which concern only one age group
especially at the level of the children or concentrate only on
the adults.39,40
It has been demonstrated that filling out a questionnaire
on fear of the dentist does not increase this very fear.41 In
addition, it has also been demonstrated that patients with a
phobia or fear are not underrepresented in epidemiological
studies on the matter.42 Let us also note that the question-
naires on the fear of the dentist are relatively free of per-
sonal bias. Namely, it appears socially accepted to be afraid
of dentists and thus few people feel the need to conceal the
truth about it.21 All too often minimized, fear of the dentist
is however not a phenomenon to be taken lightly. It is a
real public health problem, as demonstrated in this study
and in literature.9,17 A national report on the monitoring
of oral and dental health also denounced dental anxiety as
a reason for avoiding visits to the dentist for almost one
in five people.43 Doganer et al in 2017 showed that high
dental anxiety led to a reduced rate of control and these
patients only went to the clinic if they had pain.4 Although
some progress is made in teaching communication skills, it
is mainly nonspecific, given frequently by medical teach-
ers and not aimed at controlling fear. Lin et al described
in his 2017 meta analysis that dental anxiety is a critical
management step in patients with high DA but also in pain
management for all dental patients.44
In literature, the authors focus on the anxiety itself and
attempt to categorize patients with a "cut-off" system or
“threshold levels”: they attribute values to each answer;
these values are then tallied to define a threshold above
which the patient is defined as “anxious” or “phobic.” 1
In our work rather than classify patients into "anxious"
or "phobic," the focus was placed on anxiety-inducing
stimuli. The survey carried out in this work can provide
a fresh perspective on how to approach dental anxiety by
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VANHEE et al.    283

TABLE 5 Distribution of fear items according to the age group

3 to 6 (n = 109) 7 to 12 (n = 267) 13 to 17 (n = 180)

No Fear Fear No Fear Fear No Fear Fear

Missing (<2) (≥2) Missing (<2) (≥2) Missing (<2) (≥2)

Age - Categories n % % % n % % % n % % %
Day before 0 0 79.8 20.2 0 0 83.6 16.4 0 0.0 90.0 10.0
Waiting room 0 0 84.4 15.6 0 0 82.0 18.0 0 0.0 83.4 16.6
Dentist's chair 0 0 87.1 12.9 1 0.4 81.7 17.9 0 0.0 70.5 29.5
Taste 11 10.1 75.2 14.7 10 3.7 81.6 14.7 1 0.6 88.4 11.0
Smell products 10 9.2 69.7 21.1 10 3.7 79.4 16.9 1 0.6 87.2 12.2
Smell dental office 2 1.8 81.7 16.5 7 2.6 89.5 7.9 0 0.0 92.8 7.2
Seeing syringe 5 4.6 41.3 54.1a 7 2.6 43.9 54.5a 6 3.3 47.7 49.0a
Feeling injection 10 9.2 47.7 43.1a 10 3.7 45.7 50.6a 8 4.4 42.2 53.4a
Local anaesthesiab 37 33.9 50.5 15.6 49 18.4 62.5 19.1 24 13.3 62.8 23.9
Mouth wake upb 37 33.9 59.7 6.4 48 18 69.7 12.3 25 13.9 75.0 11.1
Seeing drill 6 5.5 68.8 25.7 8 3 69.6 27.4 4 2.2 64.4 33.4
Drill vibrations 21 19.3 53.2 27.5 14 5.2 65.6 29.2 6 3.3 59.5 37.2a
Hearing drill 6 5.5 71.6 22.9 9 3.4 78.0 18.6 5 2.8 73.9 23.3
Seeing saliva ejector 8 7.3 81.7 11.0 12 4.5 88.4 7.1 4 2.2 95.0 2.8
Feeling water suction 11 10.1 78.0 11.9 11 4.1 86.9 9.0 4 2.2 91.1 6.7
Seeing instruments 2 1.8 82.6 15.6 8 3 76.4 20.6 2 1.1 80.0 18.9
Feeling instruments 3 2.8 74.3 22.9 8 3 74.6 22.4 6 3.3 73.9 22.8
Light in the face 2 1.8 82.6 15.6 10 3.7 89.2 7.1 2 1.1 94.5 4.4
Position 2 1.8 87.1 11.1 10 3.7 89.6 6.7 2 1.1 92.8 6.1
Not being able to talk 2 1.8 80.7 17.5 11 4.1 76.4 19.5 3 1.7 80.0 18.3
Something in mouth 4 3.7 80.8 15.5 10 3.7 75.7 20.6 3 1.7 78.9 19.4
Rubber damb 96 88.1 11.0 0.9 198 74.2 19.8 6.0 120 66.7 25.0 8.3
Clothes 2 1.8 85.3 12.9 12 4.5 90.2 5.3 5 2.8 92.8 4.4
a
Seeing blood 10 9.2 56.0 34.8 13 4.9 67.8 27.3 3 1.7 75.5 22.8
Taste blood 13 11.9 57.8 30.3 15 5.6 69.3 25.1 4 2.2 75.5 22.3
Tooth extraction 3 2.8 62.3 34.9a 12 4.5 43.8 51.7a 5 2.8 37.3 59.9a
a
Told that cavity 6 5.5 72.5 22.0 12 4.5 62.9 32.6 5 2.8 58.3 38.9a
Not being able to see 5 4.6 70.7 24.7 12 4.5 69.6 25.9 2 1.1 68.9 30.0
a a
Being admonished 5 4.6 63.3 32.1 15 5.6 64.4 30.0 8 4.4 75.0 20.6
a
The five highest percentages for each age group.
b
Most frequent missing data.

proposing a solution which covers both individual and
overall dimensions of dental anxiety. An advantage is that
the practitioner can ask these questions directly to the pa-
tient on the fly or let the patient fill out the questionnaire
himself while in the waiting room, along with his personal
medical record for example. Depending on the age of the
patient, this should only take 2 to 4 minutes.
Our analysis shows that the most anxiety stimuli con-
cern invasive dental procedures and in particular the top-
ics about the local anaesthesia. Tuk et al compared in
their study the feeling and physiological response between
patients with intense DA and those not afraid at all. If a
difference was shown at the feeling level, this was not the
case at the level of the physiological response. It is however
important to take all the elements into consideration for the
well-being of patients.45 Even though some of these proce-
dures are simply unavoidable, it might be useful to improve
certain of its aspects. As a matter of fact, our study reveals
that a dentist with a negative or judgmental attitude is dis-
tressing for the patient. Some studies have even pointed
out that pain caused by a dentist perceived as friendly and
helpful had less psychological impact than that imposed by
 |
284   
a dentist seen as distant and cold. Similarly, for children,
positive or neutral visits prevent traumatic experiences that
could otherwise to a certain extent have been the source
of dental anxiety.46 Thus, by acting on related elements
(attitude, general environment, etc) it could be possible to
establish an atmosphere of trust in which the concerns of
patients would greatly be alleviated. The appearance of the
dentist is also be shown to influence the degree of fear in
young children.47 Hence, once again, the need for practi-
tioners to be seriously trained in communication is undis-
putable. Dedicated seminars, distraction, and hypnosis are
but a few avenues that have been explored with unmistak-
able success.48
While the descriptive analysis classified the items in
descending order of results in the questionnaire, statistical
analysis by logistic regression showed that there was no in-
dependent variable that particularly influenced the percep-
tion of the ENV category. On the other hand, for LA and
INT, the gender variable shows a significant impact. In the
case of LA, the ethnic origin influence is different. Indeed,
the anticipation of an LA is often influenced by the way the
family circle describes this situation. At the same time, an
LA well done with all the precautions of use as the warm-
ing of the carpule, the good pose of the bevel of the needle
on the mucous membrane, the slow injection of the product
of anaesthesia, is a short act and almost painless. It can
thus be understood that the influence of the independent
variables is limited to this level. On the other hand, for the
INT, the independent variables that significantly influence
this category are more in the order of the patient's personal
experience. When a patient has had negative experiences,
many visits to the dentist and the heaviness of the care that
he had to be referred to hospital, he has probably a real
personal expertise of the dental act. Indeed, by knowing
the dental procedure, it is quite easy to realize that during
a dental treatment, the environment quickly passes in the
background, local anaesthesia is finally a very short time
compared with the intervention which can sometimes be
unpleasant for many reasons as shown by the high number
of items related to this category in the questionnaire. This
study made it possible to identify not only what is scary but
also to cross the variables in order to extract the elements
that make it possible to identify the heart of the problem,
namely the dental technical act itself. Anticipation of the
dental procedure is also a source of anxiety. Arranging the
waiting room so as to make it a pleasant place seems to
decrease patients’ apprehension. Similarly, a friendly re-
ception staff and assistant are liable in the future to play an
increasing role in the success of a rewarding relationship
between the patients and their dentist.46 A door is therefore
left open for many investigations to follow in the future.
Indeed, several questions remain unanswered such as “why
do children aged 3 to 6 years express less fear?” and “what
1365263x, 2020, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ipd.12595 by University Of Debrecen, Wiley Online Library on [09/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VANHEE et al.
strategies should be implemented to prevent or cure dental
anxiety?”. Qualitative studies may also be worth consider-
ing in further research.
CONFLICT OF INTEREST
All authors declare having no financial interest or conflict of
interest.
AUTHORS’ CONTRIBUTIONS
Mourali S. and Vanden Abbeele A. conceived the ideas;
Mourali S. collected the data; Vanhee T. and Jacquet W.
analysed the data; and Vanhee T. and Bottenberg P. led the
writing.
ORCID
Tania Vanhee https://orcid.org/0000-0001-7608-4368
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How to cite this article: Vanhee T, Mourali S,
Bottenberg P, Jacquet W, Vanden Abbeele A. Stimuli
involved in dental anxiety: What are patients afraid
of?: A descriptive study. Int J Paediatr Dent.
2020;30:276–285. https​://doi.org/10.1111/ipd.12595​