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Demystifying behaviour and dental anxiety in schoolchildren during

endodontic treatment for primary teeth - controlled clinical trial

Article  in  International Journal of Paediatric Dentistry · January 2019

DOI: 10.1111/ipd.12468

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Josiane Pezzini Soares Mariane Cardoso

Federal University of Santa Catarina Federal University of Santa Catarina
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Michele Bolan
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Received: 10 August 2018 
|   Revised: 14 December 2018 
|
  Accepted: 10 January 2019

DOI: 10.1111/ipd.12468

ORIGINAL ARTICLE

Demystifying behaviour and dental anxiety in schoolchildren

during endodontic treatment for primary teeth—controlled
clinical trial

Josiane Pezzini Soares   | Mariane Cardoso | Michele Bolan

Department of Paediatric Dentistry, School

of Dentistry, Federal University of Santa
Background: Behaviour and anxiety of children are predictors of effective dental
Catarina, Florianopolis, SC, Brazil treatment.
Aim: Compare the behaviour and anxiety during preventive care, endodontic treat-
Correspondence
Michele Bolan, Comandante Constantino ment, and dental extraction.
Nicolau Spyrides, Florianopolis - Santa Design: Controlled clinical trial was conducted with 99 children aged 6-­9 years. The
Catarina, Brazil.
children were distributed among three groups: G1 (control)—prophylaxis and topical
Email: michelebolan@hotmail.com
fluoride; G2 (intervention)—endodontic treatment; and G3 (intervention)—tooth ex-
traction. Behaviour was measured using the Frankl scale. Dental anxiety was as-
sessed using the modified Venham Picture Test and measured at three moments:
before, during, and after the procedure. Caregivers answered a questionnaire ad-
dressing the child's previous dental experience. Clinical examinations were per-
formed by a calibrated examiner (Kappa > 0.70) for the identification of dental
caries (d-­dmft/D-­DMFT). Statistical analysis involved repeated-­measures Poisson
regression, with level of significance was P < 0.05.
Results: Neither negative behaviour nor anxiety was associated with the type of
procedure. Negative behaviour was associated with the need for restraint during a
previous dental appointment (P = 0.012). Dental anxiety was associated with age
(P = 0.037), previous difficult behaviour (P < 0.001), moment of measurement
(P < 0.001), and dental caries on permanent teeth (P = 0.001).
Conclusions: Negative behaviour and dental anxiety in children were not associated
with the type of treatment performed.

KEYWORDS
Behaviour, Child, Dental Anxiety

1  |   IN T RO D U C T ION the results of which are uncooperative behaviour and the non-­
acceptance of treatment.2 Other factors also exert an influ-
Behaviour is an important aspect of successful care in pae- ence, such as the unfamiliar environment of the dental office,
diatric dentistry. In certain situations, uncooperative be- attitude of the dentist and anxiety the child has regarding den-
haviour on the part of a child can determine the choice of tal treatment.2,4
treatment.1,2 It is therefore important to identify predictors of Dental anxiety is common problem that affects all ages, but
negative behaviour during dental treatment.3 Some children is more frequent in childhood and adolescence.3 Indeed, den-
are more vulnerable than others to their fears and impulses, tal anxiety is the most important predictor of child behaviour

© 2019 BSPD, IAPD and John Wiley & Sons A/S.     1

Int J Paediatr Dent. 2019;1–8. wileyonlinelibrary.com/journal/ipd |
Published by John Wiley & Sons Ltd
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2       SOARES et al.

in the dental setting.5,6 When faced with an uncomfortable

situation, children can resist treatment, which poses a serious Why this paper is important to paediatric dentists
obstacle to successful dental care.5 A previous study reports
an association between uncooperative behaviour and dental • It is important to understand the feelings of chil-
anxiety.6 dren with regard to the procedure to be performed,
The prevalence of uncooperative behaviour in children so that dentists can know how to address the con-
ranges from 8.9 to 25.2%7-9 and the prevalence of dental anx- cerns of these patients.
iety ranges from 14.6 to 39%.10,11 Both behaviour and anx- • This study alerts paediatrics dentists to the impor-
iety level depend on the procedure required as well as the tance of patient adaption and bonding with the
affinity between the patient and dentist.1,7 Moreover, there is dentist to make dental appointments a positive
evidence that the needle and dental drill increase discomfort memory, which can have a positive effect on fu-
and create negative expectations.7-12 ture appointments.
It is important to understand children's feelings regarding • This paper informs clinicians regarding children's
different procedures so that dentists can properly address a behaviour and dental anxiety when endodontic
child's concerns and avoid negative behaviour.5,9 However, stud- treatment and tooth extraction are performed.
ies investigating and comparing the differences in behavioural
manifestations and anxiety levels between endodontic treatment
and tooth extraction are scarce. Therefore, it is important to in-
vestigate which of these treatments has more negative impact procedures and agreed to participate in the study by signing a
on child behaviour and anxiety. Since some dentists perform statement of informed consent.
extraction of teeth with indication of pulpectomy, claiming
that the endodontic treatment leads to negative behaviour of
2.3  |  Sample calculation
the child.4,12 When there are these options, it could assist in the
decision-­making process regarding the proper clinical conduct To obtain a representative sample for the primary outcome
and acceptance of the child with proposed treatment.1,2 (behaviour), a comparison of two proportions was per-
Thus, the aim of the present study was to evaluate and formed based on a previous study, in which 66.7% of chil-
compare the behaviour and dental anxiety of children un- dren had negative behaviour prior to undergoing a tooth
dergoing preventive care, endodontic treatment, and dental extraction and 29.4% of children had negative behaviour
extraction. prior to undergoing endodontic treatment.14 Considering
an 80% test power and 5% significance level, a two-­tailed
test was established, determining a minimum of 27 chil-
2  |  M AT E R IA L A N D ME T HODS
dren per group, to which 20% was added to compensate for
possible losses (questionnaires returned blank), leading to
2.1  |  Study design
a total 99 children.
The present non-­ randomised controlled clinical trial was
registered with the Brazilian Clinical Trials Registry (reg-
2.4  |  Participant screening and
ister: RBR-­ 7fpgzg) and follows the guidelines of the
eligibility assessment
Transparent Reporting of Evaluations with Nonrandomized
Designs (TREND).13 Data collection was done in the city of After taking the patient histories, children aged 6-­9 years were
Florianopolis and the study was conducted between January submitted clinical and radiographic examinations to identify
and December 2017 with children aged 6-­9 years and their the ideal treatment. The children and their caregivers were
caregivers. The children were distributed according to the then invited to participate in the study if they met the follow-
need for treatment among three groups: G1 (control)—proph- ing inclusion criteria: need for at least one procedure (preven-
ylaxis and topical fluoride; G2 (intervention)—endodontic tive/prophylaxis and topic fluoride, endodontic treatment in
treatment in primary molars; and G3 (intervention)—extrac- primary molars or extraction of primary molars); non-­use of
tion of primary molars. medications that affect the central nervous system. Exclusion
criteria were as follows: patient with special needs; caregivers
not able to understand the questionnaire; treatments that could
2.2  |  Ethical approval
not be completed by the main operator due to technical diffi-
This study received approval from the Human Research culty. Only one procedure per child was included in this study.
Ethics Committee of the State University of Santa Catarina A single dentist who had undergone training and calibra-
(certificate number: 2.308.475/2017). The caregivers and tion exercises performed the procedures, using the same proto-
children received clarifications regarding the objectives and col for all the patients to control for possible bias. The dentist
SOARES et al.   
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|

F I G U R E   1   Study diagram

was also trained to apply the behaviour management tech- anaesthesia?” (no or yes); “The last time your child went to
niques in case of need techniques to perform the procedures. the dentist, was there a need to hold (restrain) him/her down
All procedures were performed in a single session. The details for the procedure?” (no or yes); “How would you describe
on patient recruitment are presented in the diagram (Figure 1). your child's behaviour the last time he/she child went to the
dentist?” (“good”, “fair” or “poor”).
The children's behaviour during dental treatment was as-
2.5  |  Pilot study and calibration
sessed in the same session by the main operator using the
A pilot study involving 18 children 6-­9 years of age was con- Frankl behaviour rating scale.15 This scale was scored as
ducted prior to data collection (between January and March follows: definitely negative; negative; positive; or definitely
2017) to test the proposed methodology. The children in the positive. For statistical purposes, the result of the rating scale
pilot study were not included in the final sample. The data was dichotomised as either positive (definitely positive or
revealed no need to alter the methods proposed for the study. positive) or negative (definitely negative or negative).
An experienced researcher and specialist in paediatric den- Child dental anxiety was assessed using Modified Venham
tistry guided the training and calibration exercises of the ex- Picture Test (VPTm)16 at three moments: (a) prior to any
aminer regarding the administration of the Frankl Behaviour treatment or examination; (b) during treatment (use Robson
Rating Scale and modified Venham Picture Test as well as brush for prophylaxis [G1]; during administration of anaes-
the execution of the procedures (prophylaxis/topic fluoride, thesia prior to endodontic treatment [G2] or tooth extraction
endodontic treatment, and tooth extraction). Inter-­examiner [G3]); and (c) at the end of treatment. The VPTm consists
agreement was determined using the Kappa index (K = 0.87). of eight cards with drawings of a female child for girls or
male child for boys. Each card has a non-­anxious child (score
0) and an anxious child (score 1). The children were asked
2.6  |  Outcomes measures/data collection
to choose the figure on each card that most reflected their
The caregivers were present when the treatments were per- feelings at the time. The sum of all cards ranged from 0 to 8.
formed and answered a questionnaire addressing socioeco- For statistical purposes, the children were classified as either
nomic and demographic information. The caregivers also non-­anxious (total: 0) or anxious (total: ≥1).
answered the following questions regarding the child's den- Each child's vital signs were measured with an oximeter
tal history and behaviour: “Has your child ever had dental (MD 300C1 ChoceMMed™, Hamburg, Germany) to evaluate
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4       SOARES et al.

pulse rate as a concrete indicator of anxiety during the same and topical fluoride (n = 33); G2 (intervention)—endodon-
three moments that the VPTm was administered (before, tic treatment in primary molars (n = 33); and G3 (interven-
during, and after treatment). The normal pulse rate for chil- tion)—extraction of primary molars (n = 33). Mean age was
dren aged 6-­11 years is 75-­118 (beats per minute [bpm]) and 7.16 (SD ±1.0) years and 6 years was the most frequent age
oxygen saturation should be >92%.17 The pulse rate was (32.3%). The prevalence of negative behaviour and anxiety
classified as normal (75-­118 bpm), high (>118 bpm), or low was 14.1% and 40.4%, respectively. The prevalence of anxi-
(<75 bpm), and oxygen saturation was classified as either ety before, during, and after treatment was 41.4%, 56.6%, and
normal (>92%) or low (<92%). 24.2%, respectively.
The clinical evaluation was performed by a single dentist Table 1 displays the distribution of the behaviour ratings
who had undergone a calibration exercise (κ > 0.70) using the according to type of treatment. No significance difference
criteria recommended by the Word Health Organization.18 The was found (P = 0.084). However, when dichotomised as
decayed, missing, and filled teeth (dmft/DMFT) index was positive or negative behaviour, a significant difference was
used for the determination of dental caries on primary and per- found among treatments (P = 0.020). Two children in both
manent teeth. For the analyses, only the decayed component the endodontic treatment and tooth extraction groups had
(d-­dmft/D-­DMFT) was used. Caries was classified absent (no definitely negative behaviour and five in each group had neg-
teeth with caries) or present (≥1 tooth with dental caries). ative behaviour.
The adjusted Poisson regression analysis (Table 2) re-
vealed that negative behaviour was not associated with the
2.7  |  Data analysis
type of procedure. In contrast, the negative behaviour was
The statistical analysis was performed using the Statistical 2.81-­fold more prevalent among children who had to be re-
Package for the Social Sciences (SPSS) version 21.0 program strained during a previous dental appointment (PR = 2.81;
for Mac OS (SPSS Inc, Chicago, IL, USA). Nonparametric 95% CI: 1.25-­6.30).
Kruskal-­ Wallis analysis of variance and the Bonferroni-­ Table 3 displays the results of the adjusted Poisson re-
corrected Mann-­Whitney U test were used to determine the gression analysis of dental anxiety. Age was associated with
statistical significance of differences in the children's be- anxiety (P = 0.037). Moreover, anxiety was 1.89-­fold more
haviour between treatments. Repeated-­measures Poisson re- prevalent among children with previous difficult behaviour
gression analysis with robust variance was performed to test during a dental appointment (PR = 1.89; 95% CI: 1.42-­2.50).
associations between behaviour and the independent vari- Regarding the moment of treatment, anxiety was 2.31-­fold
ables as well as between dental anxiety and the independent more prevalent during the procedure (PR: 2.31; 95% CI: 1.59-­
variables. Independent variables with a P-­value <0.20 were 3.38). Anxiety was 1.99-­fold more prevalent among children
incorporated into the adjusted model. Prevalence ratios (PR) with at least one decayed permanent tooth (PR = 1.99; 95%
and 95% confidence intervals (CI) were calculated. The level CI: 1.22-­3.23). Dental anxiety was not associated with the
of significance was set to 5% (P < 0.05). type of procedure performed.

3  |   R ES U LTS 4  |  DISCUSSION
A total of 99 children aged 6-­9  years (53 boys and 46 girls) par- In the present study, behaviour was not associated with the
ticipated in the present study. Therefore, 99 treatments were type of procedure or anxiety, but with the need for restraint
performed in the three groups: G1 (control)—prophylaxis during a previous dental appointment. Dental anxiety was

T A B L E   1   Children's behaviour during treatment (n = 99)

Fluoride Endodontic treatment Dental extraction

P-­value n (%) n (%) n (%) P-­value
Definitely positive 0.084 25 (75.8) 22 (66.7) 19 (57.6) Positive 0.020a
Positive 8 (24.2) 4 (12.1) 7 (21.2)
Negative 0 (0) 5 (15.2) 5 (15.2) Negative
Definitely negative 0 (0) 2 (6.0) 2 (6.0)
Total 33 (100) 33 (100) 33 (100)
Kruskal-­Wallis test for comparison among three groups and all behaviours.
a
Mann-­Whitney for comparison among three groups of procedure for positive and negative behaviours combined. Results significant at 5% level in bold.
SOARES et al.   
   5
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T A B L E   2   Unadjusted and adjusted Poisson regression for repeated measures of the association between negative behaviour by Frankl
behaviour rating scale and independent variables

Unadjusted Adjusted

RP IC (95%) P-­value RP IC (95%) P-­value

Sex
Male 1.00 0.654
Female 1.29 0.41-­4.07
Experience anaesthesia
No 1.00 0.201
Yes 0.50 0.17-­1.45
Restraint previously
No 1.00 <0.001 1.00 0.012
Yes 4.66 2.00-­10.85 2.81 1.25-­6.30
Previous behaviour
Good 1.00 0.024 1.00 0.186
Fair 3.79 1.33-­10.77 2.28 0.76-­6.82
Poor 6.00 1.15-­31.11 1.31 0.28-­5.98
Type of procedure
Endodontic treatment 1.00 0.757
Dental extraction 0.88 0.40-­1.93
Pulse rate
Normal 1.00 0.010 1.00 0.144
High 0.20 0.03-­1.32 0.26 0.03-­1.91
Low 3.01 1.17-­7.76 2.24 0.72-­7.01
Oxygen saturation
Normal 1.00 0.586
<92% 0.58 0.11-­2.96
Anxiety
No anxious 1.00 0.040 1.00 0.97-­3.48 0.060
Anxious 1.95 1.03-­3.72 1.84
D-­DMFT
Absent 1.00 0.264
Present 1.89 0.61-­5.82
Adjusted by restraint previously, previous behaviour, pulse rate, and anxiety. *The variables age, G1-­prophylaxis/topic fluoride, and d-­dmft there were 0 patients with
negative behaviour, so it was not possible to insert in this analyse. Results significant at 5% level in bold.

also not associated with the type of procedure, but with age, perceptions regarding dental treatment, but the assessment
previous behaviour, moment of treatment, and dental caries of behaviour and dental anxiety is limited since there is no
in permanent dentition. comparison in both invasive procedures as endodontic treat-
The non-­ association between behaviour and anxiety ment and dental extraction, making it difficult to compare the
shows that schoolchildren can handle their fears. Regardless present results to previous findings.6-8,14,19
of endodontic treatment or dental extraction, acceptable be- The fact that age was associated with dental anxiety was
haviour, and good control of dental anxiety was found. Thus, expected, given that maturation increases over time in chil-
the paediatric dentists can feel more secure with regard to the dren.20,21 However, children at this age can understand the
behaviour of children even during invasive treatments. The importance of the procedure they are about to undergo and
concern that some interventions generate greater anxiety than can control their dental anxiety, enabling the dentist better
others and that this anxiety can lead to negative behaviour management of the child. A previous study found that neg-
was not identified in the age group analysed. Previous stud- ative behaviour decreases with age.12 Therefore, children
ies have investigated the type of procedure and children's between 6 and 9 years of age are expected to have greater
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6       SOARES et al.

T A B L E   3   Unadjusted and adjusted Poisson regression for repeated measures of the association between presence of dental anxiety and
independent variables

Unadjusted Adjusted

RP IC (95%) P-­value RP IC (95%) P-­value

Sex
Male 1.00 0.787
Female 1.05 0.71-­1.55
Age (y) 0.037
9 1.00 0.119 1.00
8 1.90 1.07-­3.35 1.89 1.15-­3.12
7 1.29 0.78-­2.13 1.36 0.85-­2.17
6 1.53 0.83-­2.80 1.42 0.84-­2.41
Experience anaesthesia
No 1.00 0.445
Yes 1.15 0.80-­1.65
Restraint previously
No 1.00 0.481
Yes 1.16 0.76-­1.78
Previous behaviour
Good 1.00 <0.001 1.00 <0.001
Fair 1.09 0.75-­1.58 1.17 0.81-­1.71
Poor 1.73 1.45-­2.07 1.89 1.42-­2.50
Type of procedure
Prophylaxis and topic 1.00 0.046 1.00 0.197
fluoride
Endodontic treatment 1.59 1.02-­2.47 1.57 0.80-­3.07
Dental extraction 1.69 1.10-­2.57 1.59 0.91-­2.77
Moment of treatment
After 1.00 <0.001 1.00 <0.001
Before 1.72 1.09-­2.73 1.72 1.09-­2.73
During 2.32 1.59-­3.38 2.31 1.59-­3.38
Pulse rate
Normal 1.00 0.943
High 0.92 0.59-­1.44
Low 1.02 0.45-­2.39
Oxygen saturation
Normal 1.00 0.216
<92% 0.40 0.09-­1.70
d-­dmft
Absent 1.00 0.020 1.00 0.573
Present 1.58 1.07-­2.33 1.18 0.70-­1.98
D-­DMFT
Absent 1.00 0.089 1.00 0.001
Present 1.35 0.95-­1.91 1.99 1.22-­3.23
Adjusted by age, previous behaviour, type of procedure, moment of treatment, D-­DMFT, and d-­dmft. Results significant at 5% level in bold.
SOARES et al.   
   7
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control over their behaviour. The more a dentist understands due to the treatment characteristics. For the same reason,
dental anxiety, the better he/she will be able to guide accept- randomisation was not possible. However, control measures
able behaviour on the part of the patient.5,9 were taken, such as the controlled environment, use of only
The same number of children had negative behaviour one operator, use of the same anaesthetic solution and mea-
during both invasive dental procedures, whereas none of the surement scales, the timing of the procedures and the com-
patients in the control group (prophylaxis and topical fluo- parison of the results to a control group (prophylaxis and
ride) had negative behaviour. Invasive procedures cause more topical fluoride).13,30
aversive behaviour due to the fear that treatment will be pain- The clinical relevance of this study resides in the en-
ful, will involve forceful movements and discomfort, and will couragement of performing endodontic treatment in the
require anaesthesia.6,7,22 primary dentition, since this form of treatment was not as-
In this study, behaviour was associated with the need for sociated with greater negative behaviour or greater dental
restraint during a previous dental appointment. This suggests anxiety. When preventive care is not an option and invasive
that an unpleasant past dental experience is a predictor of a treatment is needed (either endodontic or tooth extraction),
child's cooperation, as difficult treatment and lack of a bond clinicians should emphasise the fact that endodontic treat-
with the professional hinder a child's acceptance of dental ment maintains the tooth in the oral cavity and explain to
treatment.2,19 This finding underscores the importance regu- caregivers that both forms of treatment are invasive and
lar visits to the dentist for the purposes of prevention when a have similar levels of acceptance on the part of the child.
child is young so that he/she will be more likely to accept an This could help demystify the caregiver's apprehension
invasive treatment due to the understanding that it is for his/ with regard to endodontic treatment, since these have the
her own good.2,23 Moreover, the fact that children who exhib- perception of pain from treatment in permanent dentition.31
ited difficult behaviour during a previous dental appointment However, in primary teeth the perception of pain is differ-
demonstrated dental anxiety may be explained by the mem- ent, due to the characteristics, such as anatomy, vasculariza-
ory of the past negative experience and the expectation that tion, and complexity.32
the current experience will occur in the same manner.6,12,24 Based on the present findings, regardless of prophy-
The greater anxiety measured during the administration laxis/topical fluoride, endodontic treatment, or dental
of anaesthesia was expected, since fear of the needle, the dis- extraction, there is no association between negative be-
comfort of the injection and the lack of control in this sit- haviour and dental anxiety in schoolchildren. In contrast,
uation cause high levels of anxiety.6,7,25 Although this was the need for restraint during a previous dental appointment
the most anxious moment, the children's behaviour was not was a determinant of negative behaviour and age, previ-
altered. Dental caries is the most prevalent problem, and usu- ous difficult behaviour, moment of local anaesthesia, and
ally is required anaesthesia for treatment, so these children dental caries in permanent dentition were determinant of
already have previous experience with anaesthesia and it is dental anxiety.
known that this is associated with dental anxiety.26 Therefore,
dental anxiety was associated with dental caries in permanent
ACKNOWLEDGMENTS
dentition in this study, in agreement with findings described
in previous studies.27 Soares (2017) found that experiences This study was financed in part by the Coordenação de
with dental caries increase the chance of dental anxiety in Aperfeiçoamento de Pessoal de Nível Superior – Brasil
childhood and a greater number of decayed teeth or teeth (CAPES) – Finance Code 001.
indicated for extraction constitute a greater risk of develop-
ing high dental anxiety.28 Dentists who perceive exacerbated
CONFLICT OF INTEREST
anxiety or fear should direct such patients to effective psy-
chological treatment to learn how to cope with anxiety.29 The authors declare that they have no conflict of interest with
This study has positive aspects that should be stressed. respect to the authorship or publication of this article.
Behaviour was measured using a scale considered the gold
standard for this purpose.15 Dental anxiety was measured using
AUTHORS’ CONTRIBUTION
a validated scale with pictures of faces that is easily understood
and has a high degree of reliability.16 All procedures were per- Josiane Pezzini Soares was responsible for study design re-
formed by a single trained and calibrated operator to minimise cruitment of participants, collected the data, analysed and in-
the risk of bias. However, the study was conducted with a non-­ terpretation the data, drafting, revision, and final approval of
probabilistic sample and the generalisation of the results to dif- the manuscript; Mariane Cardoso was responsible for a criti-
ferent populations should be performed with caution. cal revision and final approval of the manuscript; Michele
Each treatment was performed based on the needs of the Bolan was responsible for study design, critical revision, and
patient. It was not possible to blind the operator or patients final approval of the manuscript.
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8       SOARES et al.

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