A Qualitative Study on sources of Dental anxiety among Adolescents

Abstract

This cross-sectional qualitative study examines the sources of dental anxiety among adolescents aged 14-16 years in a dental camp held in a school. Dental anxiety, primarily in children, is a maladaptive cycle, which can spread through adulthood if neglected. The repercussion of this anxiety can lead to avoidance of dental care and treatment ensuing in acute dental issues necessitating invasive treatment.

The research aims to understand key determinants of dental anxiety and fear in adolescents and also investigates strategies to manage it. For this study, an in-depth interview with 30 children (16 female and 14 males) was conducted. The respondents were asked open-ended questions, seeking their perceptions and experiences leading to anxiety. The data were thoroughly transcribed and coded to identify key themes resulting anxiety in children while having dental treatment. The findings revealed that key sources of anxiety to be fear of pain, prior unpleasant experiences, negative stories and the feeling of embarrassment due to bad oral hygiene escalate anxiety in the target group. The study also indicates that certain stimuli like sharp needles and sound of dental drills adds to the level of anxiety and fear in them.

So as to mitigate different level of dental anxiety, different behavioural, psychological, and pharmacological interventions were explored as effective methods.  The findings emphasised the importance of compassionate communication, parental support, and a child-friendly environment in taming anxiety during dental treatments. The intervention should be tailored according to personal characteristics of the patients and intensity of anxiety.

Introduction

Background of the study:

Dental anxiety, a maladaptive cycle, which leads to delay or avoidance of dental treatment, which causes dental problems that are related to more invasive or even emergency treatment, which, in turn, leads to the maintenance or exacerbation of dental anxiety (Armfield, Stewart & Spencer, 2007)

Discomfort and a fear of potential harm, often arise from either internal factors or previous experiences in one’s environment are usually a characteristic of dental anxiety. Fear of dentists has been ranked fourth among common fears (Beena, 2013). The prevalence of childhood dental fear varies from 6%-52% depending upon how it is measured, age of the children and culture (Nakai et al., 2005). Dental anxiety begins in early childhood, with highest point in early adulthood, and decline with age. Their dental behavior is usually influenced by their parents’ attitudes.

Some of the symptoms of dental anxiety may include:

• Avoidance of dental care for long time resulting tooth pain , infection or any serious issues
• Depression, crying
• Anxiety that escalates while in the waiting room
• Difficulty breathing during a dental visit etc.

Against this background, the purpose of this study was to investigate the determinants (causes) of dental fear, including the impact of age and gender in school dental camp setup among the adolescents.

Objective of the Study:

• The objective of this research is to examine the sources of dental anxiety in children of 14-16 age groups in a school camp setting.

Research Questions:

The following research questions will be formulated:

• What are the sources of dental anxiety in children aged 14-16 years in a school camp setting?
• How to manage dental anxiety in children aged 14-16 years in a school camp setting?

Literature Review:

The sources that attribute to dental anxiety among children at dental school camps in Nepal are largely undocumented. In this regard, it is crucial to determine the factors affecting each individual preference for using dental services (Gambir et al., 2013). Dental fear and anxiety in pediatric patients if neglected can also stretch into adulthood. Various instances in childhood such as painful pokes, buzzing drills, uncomfortable pressure, foreign tastes, and disturbing noises can potentially lead to dental fear and anxiety in them (Verrett & Wittenberg, 2021). Several factors such as age, sex, child’s accommodation or prior dental visits and treatment affect the children behavior at a school dental camp setting (Shinkre et al.,2024). Dental anxiety can also be induced by various factors, primarily by fears; fear of pain, blood-injury fears, lack of trust which can lead to shunning of dental care. In order to mitigate this, various psychotherapeutic, pharmaceutical or a blend of both can be used (Kumar, 2022).

Different techniques and methods are used to manage the dental anxiety and fear. One of the measures of managing dental anxiety is through Psychotherapeutic interventions. It can be approached behaviourally or cognitively. Another way to administer the anxiety is pharmacologically by using sedation or general anaesthesia. Beside this, Behaviour-modification therapies such as muscle relaxation,  breathing exercises , together with guided imagery and physiological monitoring using biofeedback, hypnosis, acupuncture, distraction, positive reinforcement, stop-signaling, and exposure-based treatments, such as systematic desensitisation, “tell-show-do”, and modeling can also help reduce the anxiety among patients (Appukuttan, 2016).Other simpler techniques include building good communication and rapport  with the dental patients (Armfeild, 2013).In recent times, the prospects of using Virtual reality in paediatric patients are getting ground as a distractive method(Rosa et al., 2023)

Materials and Methodology

Examining dental anxiety among children requires in-depth study and understanding of subtle nuances and cues of the history of dental experiences. The degree of dental anxiety among them can be shaped by patient characteristics as well as different clinical situations. While using numbers can generate data, it often doesn’t fully capture the dynamics, reasons and beliefs that induce anxiety in the target group. To overcome this limitation, qualitative approach was used.

The target group included patients whose age ranged from 14-16 years in a dental camp held in a school. Around 30 children were selected for the in-depth interview each for about 15-20 minutes. Among the study group of 30 patients, 16 were female while 14 were male.  This interview took the form of informal conversations between the research patients and the researcher. Before each interview, researcher established rapport, trust and sought permission for recording the conversation so that patients feel comfortable to express their perspective and experiences. The consents were taken from their school teachers in behalf of their parents and assured confidentiality of each patient.

 The research was administered using descriptive, cross-sectional study using an open-ended questionnaire. The study was conducted in the school camp setting for the target group. One on one interview was taken with the individual participants, which was then recorded and analyzed. This study used both primary and secondary data. Secondary data were used primarily for identifying gaps in prior research and to formulate research questions and objectives, through different published journals and articles, whereas, primary data was mainly collected from 30 respondents after which it was synthesized and analyzed to derive insights.

The questions included for the research are:

1. Have you ever visited a dental clinic or dental hospital?
2. How do you feel when you visit the dentist?
3. What makes you feel comfortable or uncomfortable in the dental office?
4. What sounds, smells, or sights in the dental office make you feel nervous or scared?
5. Can you remember a time when you felt scared during a visit to the dentist? What made you feel that way?
6. How do the people in the dental office make you feel?
7. Are there any others, outside the dental environment, that you believe influence your fear of dental visits?

The recordings were then duly transcribed after every five interviews in order to maintain the accuracy and annotate each nuance. The field notes and transcription was promptly reviewed and summarized. The transcribed notes were then coded and categorised into different themes and subthemes using MAXQDA Software (MAX Qualitative Data Analysis).

Result and Discussion

The result showed majority of female children were suffering from dental anxiety in this study. Among many sources for dental anxiety, fear of specific stimuli (pain) was reported to be the primary cause for anxiety in the study group, followed by the past medical experience and also the feeling of embarrassment due to their oral hygiene.

• My dentist keeps scolding me for not keeping teeth in good shape and disregarding oral hygiene. I feel very embarrassed. Thinking about it makes me anxious. (Interviewee #R19, Student 2^nd December 2024).

• My dentist was rough, and I felt like they weren’t listening when I said something hurt. That memory just sticks with me, and now I’m scared it will happen again. (Interviewee #R27, Student, 2^nd December 2024).

The study revealed that anxious children were particularly concerned about needles and dental drills, both of which they associate with the pain.

• On my previous visit to a dentist, they gave a shot in my gums, which hurt a lot- I couldn’t stop crying. (Interviewee #R8, Student, 2^nd December, 2024).

• The dentist I visited for tooth extraction was rough; I felt he wasn’t listening when I said it caused pain when he poked a sharp object in my mouth. The pain still is fresh in my memory and I am scared it’ll repeat again. (Interviewee #R6, Student 2^rd December 2024).

The research indicates dental anxiety is commonly seen in children below 16 years. Several themes is found to be associated with the dental anxiety like perception of pain, negative stories regarding the treatments, certain smells and sound from the dental clinic. During the interview, children with dental anxiety have visibly sweaty palms and reported to have rapid heart rate.

• I don’t like the smell of hospital and clinics. It makes me nauseous. On the top of that, hearing other patients in the waiting room having severe pain and crying out loud makes it worse for me. I also hear sounds of something that is piercing in my ears. It makes me uncomfortable and I cannot sit in the chair still. (Interviewee #R22, Student, 2^nd December, 2024).

• My niece once told me that once a sharp needle poked through her gums making her bleed. I am scared of blood. Also, she said that cleaning her teeth in the clinic make her bleed. I am scared to visit the dentist for this reason. (Interviewee #R11, Student, 2^rd December, 2024).

The study highlights the challenges and emotional distress some children feel during dental checkups, emphasising the need for understanding and compassionate care during the checkups.

The key to overcoming dental anxiety is the communication. To treat children, dentists need to assess the patient in relation to personal, social and environmental aspects, and assessments need to be carried out using well established methods to gain more knowledge about the individual patient. Dental anxiety management can also be done using combination of psychological, behavioural, pharmacological and environmental approaches. Different management intervention can be used depending on the level of dental anxiety, personal characteristics of patients as well as clinical situations. Some of them are:

1. Understanding the individual (patient)

• Reason for the anxiety may be due to Previous negative experiences like uncomfortable or painful event in the past
• It may be  due to unknown fear like sounds, smell and unfamiliar environment
• Social media influences showing negative comments about dentistry can trigger the fears.

2. Behavioural Management Technique

• Behavioural Management Technique
• Positive reinforcement :  Praise and Gifts for good behaviour during the appointment
• Demonstration of the dental procedure (Tell-show-do technique)
• Modeling technique
• Distraction techniques
• Soothing music and relaxation techniques

3. Parental Support

• Parental Support
• Involvement of parents plays one of the major roles for managing children with dental anxiety. They should be instructed to stay calm and positive during the treatment. Children do feel secure when accompanied by their parents during the dental visit.

4. Others

• Pharmacological management includes  local anaesthesia and sedation
•  (Especially for extensive treatment)
• Creating Child-friendly environment
• Teaching the children about importance of oral hygiene and regular dental checkup will help them to understand that dental care is normal and necessary

Conclusion:

This study investigates the sources and management of dental anxiety in adolescents aged 14-16 years in a school dental camp setting. The findings revealed that dental anxiety arises from multiple factors, including fear of pain, prior negative experiences, and embarrassment over oral hygiene, and sensory triggers such as the sound of drills and the smell of clinical environments. The results underline the importance of understanding the unique triggers and personal characteristics of each patient which is fundamental in delivering effective dental care. Further studies should focus on longitudinal effects and diverse population samples to develop insights for improving oral health outcomes and breaking the cycle of dental anxiety in children.

References:

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