Key Points
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Encourages clinicians to conduct formal assessment of children's dental anxiety using validated questionnaires in line with SDCEP guidelines' recommendations.
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Raises a question on parents'/guardians' judgment of their child's dental anxiety and encourages children's self-reported dental anxiety assessments.
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Describes children's self-reported dental anxiety to be present in 18% of study participants.
Abstract
Background Healthcare professionals often rely on parents to provide accurate dental anxiety assessment for their children. To date no studies have reported on inter-rater agreement between children's self-reported and their parents'/guardians' proxy-reported dental anxiety in the UK.
Aims To assess the frequency of self-reported dental anxiety in 7–16-year-old children and the inter-rater agreement between children's self-reported and parent/guardian proxy-reported dental anxiety for their children.
Methods Data were collected prospectively from 7–16-year-old children and their parents/guardians attending two community dental clinics in Fife, Scotland (July 2012–January 2013). Dental anxiety was assessed using faces version of Modified Child Dental Anxiety Scale. Questionnaires were separately and independently completed by children and their accompanying parent or guardian.
Results One hundred and thirty-two child-parent/guardian pairs participated in this study. Children's self-reported dental anxiety was 18% (n = 24, 95% CI 12–25). Inter-rater agreement between children and their parent/guardian was poor for dental filling (linear weighted kappa coefficient 0.17) and tooth extraction (0.20), whereas other questions had fair inter-rater agreement (0.21–0.34). Parents' proxy-reported assessments significantly failed to recognise dental anxiety in 46% (n = 11) dentally anxious children (p = 0.0004).
Conclusion Parent/guardian proxy-reported dental anxiety differs from children's self-reported dental anxiety suggesting children should be encouraged to self-report their dental anxiety.
Main
H.Patel, C.Reid, K.Wilson and N. M.Girdler British Dental Journal 2015; 218: E6
Editor's summary
I sometimes wish I had a time machine to allow me to be a child again for a while. To be honest, I wish I could at least remember what it really felt like to be a child. Like you all I'm sure, now and again I get flashbacks about being young and happy, doing simple things like eating jam sandwiches or making a corner shop by pulling everything out of the kitchen cupboards and putting prices on it all. Unfortunately, I also remember things I was frightened of, like going to the dentist. It took a long time for me to put that behind me.
As discussed recently in this Journal,1,2 current UK health policies are now making it a priority for healthcare providers to listen directly to children and young people about their treatment experiences. Traditionally, parents and guardians have been responsible for providing the 'voice of the child'. However, though they know their children incredibly well, they are not in fact in the child's head. It might be the case that parents and carers miss things or misinterpret a child's response or feelings. In relation to dental anxiety and phobia, it is not useful to miss things. It is well known that dental anxiety in paediatric patients can stay with patients throughout adulthood. Thus, the earlier we can identify dentally anxious patients the better.
This article reports on a study which compared the responses of children and their parents to a questionnaire asking about the child's experience of dental treatment. The idea being to determine the accuracy of the parent's view of their child's feelings and anxiety levels. Interestingly, these parents were better at recognising dentally non-anxious children than dentally anxious children. This result surprised me as I imagined that parents would be inclined to confuse their own dental anxiety with their child's experience of treatment.
The study is of interest to any clinician treating children. It just goes to show that it is important to get the whole picture by speaking directly to child patients. In her commentary on this paper, Annie Morgan also makes a very important point: what implications does this have for future epidemiological studies, such as the child dental health survey in the UK?
The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 218 issue 4.
Ruth Doherty
Managing Editor
Author questions and answers
1. Why did you undertake this research?
Dental anxiety and phobia are known barriers to receiving regular dental care. Around 50% of dentally anxious adults report childhood onset of their anxiety and most could relate this to negative experiences during dental treatment. Hence, identifying dentally anxious children early in life may help reduce poor oral health outcomes in these patients as adults. Healthcare professionals often rely on parents to provide accurate information regarding their child's dental anxiety. However, parents' dental anxiety can influence judgement of their child's dental anxiety and may result in overestimation or underestimation of their child's anxiety state.
Hence, this study compared the inter-rater agreement between children's self-reported dental anxiety and parents' proxy-reported dental anxiety for their children using the SDCEP-OHAR recommended Modified Child Dental Anxiety Scale-faces version (MCDASf) questionnaire.
2. What would you like to do next in this area to follow on from this work?
Regular application of easy-to-use children's self-reported dental anxiety measures in clinical practice, such as MCDASf as recommended by SDCEP-OHAR guidelines, will provide clinicians some insight into dental anxiety of children and allow open discussion into underlying causes.
For future research, a validated, predictable and easy-to-administer dental anxiety assessment tool to enable parents and clinicians to better predict children's dental anxiety would be very beneficial. This is particularly true for self-reported dental anxiety assessments in younger age group of children (3-7 years), as this is the age group where it is difficult to accurately administer self-reported dental anxiety measures.
Commentary
This informative study, carried out within the salaried primary dental care services in Scotland, sought to identify if parental-reporting of children's dental anxiety agreed with children's own self-reports of their dental anxiety. Essentially, do parents know if their child is suffering with dental anxiety?
The Scottish Dental Clinical Effectiveness Programme (SDCEP) has recommended as best practice the use of a questionnaire to assess dental anxiety as part of a comprehensive oral health assessment for all patients.1 Dental anxiety is common, affecting one in four children in the UK.2 It is associated with long-term negative consequences for oral health, with dentally anxious children more likely to: miss appointments; have untreated dental caries; experience episodes of toothache; and have an extraction carried out.2,3 It is important for dental teams to be able to identify dentally anxious young patients, so they can interpret and understand their sometimes challenging behaviour, and provide them with the support and treatment they need.
The questionnaire used in this study, and suggested by the SDCEP to assess dental anxiety in children, was a shortened (unvalidated) form of the Modified Child Dental Anxiety Questionnaire (faces version).1 The original measure was developed for children to complete themselves.4 However, in dentistry researchers and clinicians have traditionally asked parents to act as a proxy for children and answer clinical questions on their behalf.5 So, do parents in the UK know if their child is dentally anxious, or not? According to this study, parents were good at identifying if their child was not dentally anxious, but 50% of parents with dentally anxious children failed to recognise it. This was surprising as 15% of the study participants had been referred from general dental practice for the management of dental anxiety. Interestingly, a similar study carried out in Sweden found that Swedish parents didn't do any better, with parents of dentally anxious children often over-estimating the levels of anxiety in their child, and parents of non-dentally anxious children under-estimating it.6
The findings of this study have important implications for national surveys of children's oral health, which have in the past relied on parental ratings to measure children's dental anxiety.2 Consequently, we may fail to have a true picture of the extent of dental anxiety in children and young people across the UK.
References
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Morgan, A. Summary of: Inter-rater agreement between children's self-reported and parents' proxy-reported dental anxiety. Br Dent J 218, 236–237 (2015). https://doi.org/10.1038/sj.bdj.2015.125
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DOI: https://doi.org/10.1038/sj.bdj.2015.125
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