1. Introduction
Dental anxiety (DA) is defined as a strong, negative feeling associated with a dental procedure, regardless of the general condition, preceded by a negative dental experience [
1,
2]. Dental anxiety is a universal phenomenon that affects patients regardless of their age and negatively influences the quality of life related to oral health in children and adults [
3]. The patient’s experience is subjective and can vary greatly depending on the person’s physical and mental condition [
4]. Sometimes, a child may express their fears and anxieties, while others may express them through behaviors such as crying, fussing, interrupting conversations or play, and even trying to run away from the caregiver. It can also be accompanied by significant physical changes, such as an increase in heart rate, other hemodynamic changes and the release of stress hormones [
5].
The main effects of dental fear are deterioration in oral health and the perpetuation of a vicious cycle of avoiding or canceling already scheduled appointments. Dental appointments are only attended when pain or major discomfort occurs, which further increases the feeling of anxiety [
6]. Fear of the dentist is one of the main causes of irregular visits to the dental office, along with a lack of time, financial resources and accessibility of the office staff [
6]. The prevalence of dental anxiety in children varies between 5 and 33% depending on the study [
1]. The causes of dental anxiety can be divided into several categories: biological causes (individual temperament, genetics and epigenetics) [
7], social causes (parental dental anxiety, family socioeconomic status (SES), parental adjustment before dental procedures and parental expectations of children’s behavior in the dental environment) and factors of the dental environment related to the appearance of the dental office, treatment and surroundings [
8]. There are currently no well-defined treatment or control options for dental anxiety. Further research is needed to make treatment more accessible and to provide dental procedures adapted to patients with dental anxiety through additional education of dentists [
9].
Children behave differently during dental procedures. Therefore, a dentist must know the characteristics of the child’s psychological development, which depend on the child’s age, so that he can respond to each patient individually [
10]. Managing children’s behavior during dental treatment is extremely important. Poorly controlled pain affects the child’s well-being and may lead to a decreased ability to effectively manage future pain [
11]. Dental anxiety can be controlled by psychotherapeutic interventions, pharmacological interventions, or a combination of both, depending on the dentist’s expertise and experience, the degree of dental anxiety, the patient’s characteristics and the clinical situation [
12]. Dental anxiety can vary from very mild to extreme and interacts with the urgency of treatment, so different approaches to reducing anxiety may be appropriate depending on the level of anxiety [
13]. Some treatment methods can reduce anxiety. With an appropriate approach adapted to the age of the child or patient and a detailed explanation of the procedure, we can influence the reduction in anxiety. Patients may show less anxiety for treatments that do not require anaesthesia such as minor anterior restorations [
14] or bleaching procedures [
15]. A good relationship between the patient and dentist is key to managing anxiety.
Several factors influence a child’s oral health, from the child’s behavior to family and society. Parental variables that are directly related to children’s oral health include sociodemographic characteristics, oral health behaviors, knowledge, fears, and many others. Since the family environment influences the children’s oral habits, it is necessary to assess not only the child’s oral status, the presence of carious lesions and concomitant clinical situations in the child, but also related family factors [
16]. Goettems et al. [
17], who investigated the relationship between the influence of maternal dental anxiety, the pattern of dental check-up utilization and the child’s perception of quality of life, found that children in Brazil from families with a higher socioeconomic status were five times more likely to have used dental health services than children with a lower economic status. Previous studies have suggested that socioeconomic status may be a key factor in dental anxiety, with children from the lowest socioeconomic groups showing higher levels of dental anxiety [
18]. This suggests that socioeconomic status may be a key factor in dental anxiety. However, this was not observed in the results of Amorim et al. [
18]. Ramseier et al. [
19] investigated the relationship between socioeconomic factors and dental anxiety in a group of 2240 participants aged 43.5 ± 16.0 years and found a statistically significant inverse relationship: a higher level of education correlated with a lower level of dental anxiety. The results emphasise the potential role of education in coping with dental anxiety and its impact on dental health and well-being [
19].
Back in 2001, Majstorovic et al. [
20] showed that early negative medical experiences were the main factor for the development of dental fear and that maternal dental anxiety and socioeconomic circumstances were less important factors in children aged 5.5 to 12.5 years in Croatia. The study by Škrinjarić et al. [
21] showed that maternal dental anxiety was significantly associated with the child’s dental anxiety, but not with the child’s dental health. The most recent study by Šimunović et al. [
22], which was conducted in six European countries, including Croatia, also showed a statistically significant correlation between the parents’ dental anxiety and that of the children. Research into the influence of socioeconomic status in Croatia on the development of dental anxiety in children has been insufficient.
The aim of this study was to investigate the relationship between family factors and the development of dental anxiety in children aged 9 to 12 years. This study investigated whether socioeconomic status or other parental factors could have a predictive value for dental anxiety. Knowing the predictors that may trigger dental anxiety could be very helpful for dentists in the behavioral management of their patients. Therefore, these findings could provide guidance for better promotion of oral health and thus quality of life.
The null hypothesis of this study is that the child’s dental anxiety is related to the socioeconomic status of the family and parents’ dental anxiety.
4. Discussion
Dental anxiety is a common phenomenon in children who come to the dentist’s office. Severe dental anxiety in children who visit the dental office not only leads to the failure of normal dental treatment, but also casts a psychological shadow on dental anxiety in adult patients [
25]. Assessment of dental anxiety using a questionnaire is the most commonly used method for assessing dental anxiety in pediatric patients. Since children, especially depending on the age of the child, cannot always clearly express potential dental anxiety and almost always come accompanied by their parents, questionnaires for self-assessment of dental anxiety are often used today, which the child completes independently, but parents also assess the potential anxiety felt by the child in special questionnaires [
25]. The results of this study show that the mean score of the CFSS-DS questionnaire completed by children visiting a specialist dental practice is 27.76 (SD = 8.97). This means that in the studied group of children, more than 86% of them experience some level of fear of dental procedures but do not report dental anxiety, while according to the thresholds for classification, slightly more than 13% of them have an abnormal level of dental anxiety. In their study, Wu and Gao [
1] found that 33.1% of children who completed the CFSS-DS showed dental anxiety. In total, 15.3% of the children who completed the questionnaire showed a moderate level of dental anxiety by achieving numerical scores between 32 and 39 on the questionnaire, while 17.8% of the children who completed the questionnaire achieved scores above 39, placing them in the category of children with extreme dental anxiety. Alsadat et al. [
26], who investigated the relationship between children’s dental anxiety and dental caries, reported an average CFSS-DS test score of 26.09, with only 12.50% of children reporting higher levels of dental anxiety. Differences in research results may depend primarily on cultural differences, the availability of dental care and the way a child is brought up.
Based on the research findings, we conclude that sociodemographic factors, i.e., the child’s gender and self-rated SES, as well as the dentist the child visits, whether a specialist or a primary care doctor, are not statistically significant predictors of dental anxiety in children. Shindova et al. [
27] found in their study that gender has an influence on dental anxiety. Female respondents to the CFSS-DS questionnaire reported a higher level of dental anxiety than male respondents. The study by Majstorović et al. [
28] found that dental anxiety is more common in adolescent girls than in boys. In a study of a population of children aged 6 to 12 years, cross-cultural studies on the aetiology of dental anxiety could help to clarify these contradictory findings regarding the relationship between gender and dental anxiety [
29]. At the bivariate correlation level, we found a statistically significant association between female gender and dental anxiety in children, but in the regression analysis, the child’s gender did not prove to be a statistically significant predictor.
Some authors found that the level of anxiety decreases with increasing age [
30]. Boka et al. [
31] found no statistically significant correlation between age and dental anxiety. In the study by Lima et al. [
32] with children aged 7 to 9 years, they concluded that the age of the child influenced the level of dental anxiety and emphasised that younger children have a higher level of dental anxiety. They cite the acquired ability to deal with situations that we have previously experienced as the reason for the decrease in dental anxiety. Alshoraim et al. [
33] concluded in their study that age cannot be a reliable predictor of dental anxiety in children because oral status and the influence of cultural differences significantly affect the child’s age or development and thus dental anxiety, whereas in this study we did not use age, as a predictor of dental anxiety because the age range of the children who participated in the study was very small. Uzel et al. [
34], who investigated the influence of risk factors on the development of dental anxiety, did not find increased dental anxiety in children of lower socioeconomic status. In the study by Yildirim [
35] on the adult population of periodontal patients in Turkey, a correlation was found between lower socioeconomic status and increased dental anxiety in patients. Muneer et al. [
36] investigated dental anxiety and the factors influencing it in adults and came to the conclusion that people with a lower socioeconomic status suffer more frequently from dental anxiety. In fact, socioeconomic status was a parameter for a number of behavioural, social, economic, and psychological covariates [
35]. In many countries, the utilisation of dental services is related to the availability of health care, i.e., socioeconomic status. In the Republic of Croatia, health care, including dental care, is free for children up to the age of 18, while adults pay for or have free access to health care depending on their employment status. According to Uziel et al. [
37], parents’ education level is a significant predictor of a child’s dental anxiety, with a focus on the mother’s education level, although they also mention the influence of the father’s education as a factor. The largest proportion (60.31%) of parents in our study had only completed high school. University education was reported by 22.14% of parents. On the other hand, Amorim et al. [
16] did not find increased dental anxiety in children as a function of parental educational status and note that culture and parental anxiety may influence the results of other studies that suggest a relationship between the aforementioned factors, such as the study by Rantavuori and coworkers [
38].
Although age, gender, temperament and development play a particular role in regulating children’s stress responses, perhaps the most influential factor is experience with the parents’ stress response model [
39]. It is known that children who witness their parents’ anxiety are likely to acquire such a view and consequently have painful experiences at a young age, which is a strong factor in the development of dental anxiety [
40]. On the other hand, based on their research findings, Wu et al. [
1] suggest that the child’s dental anxiety is not directly related to the parent’s dental anxiety, but is influenced by the child’s family structure and siblings, which play an important role in the development of the child’s dental anxiety. Ćorić et al. [
41] observe a statistically significant correlation between the mother’s dental anxiety and the occurrence of dental anxiety in children, although they also note the influence of the father on the child, albeit to a lesser extent. Mothers are often more involved in childcare, which could explain this phenomenon. However, due to the change in gender roles, fathers and mothers today have the same influence on child rearing. Psychological knowledge about fear in the form of an emotion that can be learned or acquired by observing the environment makes parents role models whose behaviour and expression of emotions the child tries to copy. Avoiding dental procedures, expressing fear of dental procedures, pain, injections, irregular oral hygiene and eating habits can be learned by the child from the parents or guardians [
41]. When conducting our study, a moderately positive correlation was found between the results of the CFSS-DS and the CDAS, suggesting that parents who are more likely to be dentally anxious are also more likely to be dentally anxious than their children.
With regard to the child’s behaviour and the need for dental examinations and interventions, based on the results of our study, we found no statistically significant differences in the child’s and parents’ dental anxiety between the experimental and control groups. Based on the literature reviewed, we expected that children’s dental anxiety would be higher in the group visiting a paediatric and preventive dentistry specialist. Based on our results, it appears that children are equally anxious about dentistry, even if the need to see a paediatric and preventive dentistry specialist was not identified. Krikken et al. [
42] investigated the possible relationship between children’s dental anxiety and the referral of a child to a specialty dental practise compared to a primary care dental practise and observed an increased level of dental anxiety in the group of children referred to a specialty practise. Children were most often referred to a specialty clinic for behavioural problems. The referral of a child to a specialist depends in part on the interaction between the child and the dentist and the parents. In this study, we found that there is no difference in the anxiety of children who come to paediatric and preventive dentistry specialists compared to primary care dentists. This suggests that the severity of the procedure, the dental problem or the dental environment, which differ depending on the type of procedure, have no influence on the development of dental anxiety in children. On the other hand, psychological variables and parental dental anxiety are related to the presence of dental anxiety in children. The child’s experience of visiting the dentist’s office, the child’s preparation at home for the visit or the performance of the dental procedure are more likely to be related to dental anxiety. Continuous visits to the dentist with the appearance of the first deciduous teeth in the jaw, as well as familiarization with dental procedures through games or virtual content, with the encouragement of the child and visits where the child has the opportunity to see the parent in a situation where a preventive dental examination or a necessary dental procedure is performed, are certainly recommendations that can influence the child’s later perception of the dental environment. Visits to the dental office that were not preceded by pain or discomfort related to the condition of the oral cavity, as well as the parents’ positive attitude towards dental care, can influence or contribute to reducing the child’s attitude and anxiety.
The conducted research has certain limitations. Since this research is a cross-sectional study, based on the results obtained, we can talk about the possible relationship of certain variables, but not about the direct influence of different factors on the development of dental anxiety in children. Given the dental environment and the presence of parents in the dental office as well as the examiner as a new person in the dental environment, children may show a lower level of dental anxiety to show their age-related courage and maturity. In this study, only one of the child’s parents completed the questionnaire. Therefore, we have information about his dental anxiety, but not about the anxiety of the other parent. Of course, it should be taken into account that the results of the above-mentioned questionnaire may be different for both parents.
The factors influencing dental anxiety and its negative effects in society need to be researched more comprehensively in order to obtain balanced data representing a sample of the entire population [
36]. Based on the clear and credible evidence thus collected on the influence of certain etiological factors, it would be possible to reduce the incidence of dental anxiety from an early age by educating parents and dentists with appropriate preventive measures. This will certainly improve oral health, which will have a direct impact on the quality of life of each individual. Furthermore, by identifying the key factors for the development of dental anxiety in children, it will be possible to create clear guidelines and reliable tools to assess and prevent the development of dental anxiety regardless of the child’s age, which will ultimately lead to better care for patients throughout their lives. Future studies should not only include a larger number of respondents, but also be conducted in a larger area and take into account the cooperation of several dental faculties, including the population of neighboring countries with approximately similar oral hygiene habits and similar incidence of dental caries, such as the study conducted by Šimunović et al. [
22] that includes the target population of children aged 9 to 12 years, a crucial period just before the onset of puberty. Also, future research should include parents of both sexes, an equal number of respondents in all groups and the influence of siblings on the development of dental anxiety.