Assessment of trait and state anxiety in 3-6-year old children during sequential phases of dental treatment

Original Research

Contemp Pediatr Dent 2020:1(1):22-32

Assessment of trait and state anxiety in 3-6-year old children during sequential phases of dental treatment

OrcidPriya Subramaniam1 ✉,  OrcidMaryam Haqh2,  OrcidMegha Gupta3


1. Professor and Head, Department of Pedodontics and Preventive Dentistry, The Oxford Dental College and Hospital, Bangalore, India. ( Correspondence:

2. Former Post Graduate Student,Department of Pedodontics and Preventive Dentistry, The Oxford Dental College and Hospital, Bangalore, India.

3. Reader, Department of Pedodontics and Preventive Dentistry, Vyas Dental college and Hospital, Jodhpur, India.


Dental anxiety influences children’s behavior in the operatory. An introductory dental visit is important for children, parents and the dental team.

Recording a child’s anxiety and behavior during successive appointments can assist in behavior management.

Scheduling initial appointments for preventive procedures reduces children’s anxiety and gains their cooperation at future dental visits.


Aim: To assess changes in trait and state anxiety of children during sequential phases of dental treatment. Methods: Three hundred children, aged between 3 to < 6 years, who reported for their first dental visit were included. Both parents and children were evaluated over five sequential phases of dental treatment. Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) and Modified Dental Anxiety Scale (MDAS) were used to assess child’s trait anxiety. Children’s Emotional Manifestation Scale (CEMS) and Facial Image Scale (FIS) were used to assess child’s state anxiety. Child’s behavior was rated using Frankl’s Behavior Rating Scale (FBRS). Paired sample t-test, Pearson’s Correlation coefficient and Spearman’s Rank Correlation coefficient was performed. Results: Mean CFSS-DS and CEMS scores decreased significantly from the first (26.55; 10.25) to the fifth visit (24.74; 8.1) (p<0.05). A significant decrease in the mean FIS (state anxiety) score from the first (2.70) to fifth (2.48) visit was seen (p<0.05) Children’s behavior differed significantly between the dental visits.(p<0.001) There was a significant inverse correlation between behavior and both trait and state anxiety (p<0.05). Conclusions: Sequential phases of dental treatment significantly reduced trait and state anxiety.

Keywords: Behavior Rating Scale; Child; Dental Anxiety; Dental Care

Copyright © 2020 Contemporary Pediatric Dentistry


1. Cianetti S, Lombardo G, Lupatelli E, Pagano S, Abraha I, Montedori A, et al. Dental fear/anxiety among children and adolescents. A systematic review. Eur J Paediatr Dent 2017;18:121-130

2. Jimeno FG, Bielsa SY, Fernandez CC, Rodriguez AL, Bellido MM. Objective and subjective measures for assessing anxiety in paediatric dental patients. Eur J Paediatr Dent 2011;12:239-244

3. Asl AN, Shokravi M, Jamali Z, Shirazi S. Barriers and drawbacks of the assessment of dental fear, dental anxiety and dental phobia in children: a critical literature review. J Clin Pediatr Dent 2017;41:399-423

4. Shim YS, Kim AH, Jeon EY, An SY. Dental fear and anxiety and dental pain in children and adolescents; a systemic review. J Dent Anesth Pain Med 2015;15:53-61

5. Porritt J, Buchanan H, Hall M, et al. Assessing children’s dental anxiety: a systematic review of current measures. Community Dent Oral Epidemiol 2013;41:130-142

6. Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non‐pharmacological interventions for managing dental anxiety in children. Cochrane Database Syst Rev 2017;2017:CD012676.

7. Venham L, Bengston D, Cipes M. Children’s response to sequential dental visits. J Dent Res 1977;56:454-459

8. de Menezes Abreu DM, Leal SC, Mulder J, Frencken JE. Patterns of dental anxiety in children after sequential dental visits. Eur Arch Paediatr Dent 2011;12:298-302

9. Shinde SD, Hegde RJ. Evaluation of the influence of parental anxiety on children’s behavior and understanding children’s dental anxiety after sequential dental visits. Indian J Dent Res 2017;28:22-26

10. Silveira ER, Goettems ML, Demarco FF, Azevedo MS. Clinical and individual variables in children’s dental fear: a school-based investigation. Braz Dent J 2017;28:398-404

11. Cattell RB, Scheier IH. The nature of anxiety: A review of thirteen multivariate analyses comprising 814 variables. Psychol Rep 1958;4:351-388

12. Baier K, Milgrom P, Russell S, Mancl L, Yoshida T. Children’s fear and behavior in private pediatric dentistry practices. Pediatr Dent 2004;26:316-321

13. Kuscu OO, Akyuz S. Children’s preferences concerning the physical appearance of dental injectors. J Dent Child 2006;73:116-121

14. Alshoraim MA, El-Housseiny AA, Farsi NM, Felemban OM, Alamoudi NM, Alandejani AA. Effects of child characteristics and dental history on dental fear: cross-sectional study. BMC Oral Health 2018;18:33-40

15. Sharma R. Revised Kuppuswamy’s socioeconomic status scale: explained and updated. Indian Pediatr 2017;54:867-870

16. Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child 1982;49:432-436

17. Humphris GM, Morrison T, Lindsay SJ. The modified dental anxiety scale: validation and United Kingdom norms. Community Dent Health 1995;12:143-150

18. Li HC, Lopez V. Children’s emotional manifestation scale: development and testing. J Clin Nurs 2005;14:223-229

19. Buchanan H, Niven N. Validation of a Facial Image Scale to assess child dental anxiety. Int J Paediatr Dent 2002;12:47-52

20. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? ASDC J Dent Child 1962;29:150-162

21. Anusavice KJ. Present and future approaches for the control of caries.  J Dent Educ 2005;69:538-554

22. McDonald RE. Local anesthesia and pain control for the child and adolescent. In: McDonald and Avery’s Dentistry for the child and adolescent, 9th ed. Missouri, U.S.A.: Mosby Elsevier; 2011. p.243-244

23. Majstorovic M, Morse DE, Do D, Lim LI, Herman NG, Moursi AM. Indicators of dental anxiety in children just prior to treatment. J Clin Pediatr Dent 2014;39:12-17

24. Krikken JB, van Wijk AJ, ten Cate JM, Veerkamp JSJ. Measuring dental fear using the CFSS-DS. Do children and parents agree? Int J Paediatr Dent 2013; 23:94-100

25. Bajrić E, Kobašlija S, Jurić H. Reliability and validity of dental subscale of the children’s fear survey schedule (CFSS-DS) in children in Bosnia and Herzegovina. Bosn J Basic Med Sci 2011;11:214-218

26. Tunc EP, Firat D, Onur OD, Sar V. Reliability and validity of the modified dental anxiety scale (MDAS) in a Turkish population.Community Dent Oral Epidemiol 2005;33:357-362.

27. Klingberg G, Berggren U, Norén JG. Dental fear in an urban Swedish child population: prevalence and concomitant factors. Community Dent Health 1994;11:208-214

28. Li HCW, Lopez V. Assessing children’s emotional responses to surgery: a multidimensional approach. J Adv Nurs 2006;53:543-550

29. Nakai Y, Hirakawa T, Milgrom P, et al. The children’s fear survey schedule–dental subscale in Japan. Community Dent Oral Epidemiol 2005;33:196-204

30. Veerkamp JSJ, Wright GZ. Children’s behavior in the dental office. In: Wright GZ, Kupietzky A. Behavior management in dentistry for children. 2nd ed. Iowa: Wiley Blackwell, John Wiley & Sons, Inc.; 2014.p.23-33

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26 August 2020


27 October 2020

Online First:

15 December 2020