REVIEW ARTICLE |
https://doi.org/10.5005/jp-journals-10024-3229 |
Dental Anxiety Scales Used in Pediatric Dentistry: A Systematic Review and Meta-analysis
1–6Department of Pediatric and Preventive Dentistry, Peoples College of Dental Sciences, Bhopal, Madhya Pradesh, India
Corresponding Author: Nandani Jaiswal, Department of Pediatric and Preventive Dentistry, Peoples College of Dental Sciences, Bhopal, Madhya Pradesh, India, Phone: +91 9604986494, e-mail: jaiswalnandani81@gmail.com
How to cite this article: Tiwari S, Kulkarni P, Agrawal N, et al. Dental Anxiety Scales used in Pediatric Dentistry: A Systematic Review and Meta-analysis. J Contemp Dent Pract 2021;22(11):1338–1345.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Aim: To assess various dental anxiety scales used in children and to know the effectiveness of different projective dental anxiety scales used in pediatric dentistry.
Background: Dental anxiety poses a significant problem in child patient management and is considered to be the main barrier for successful completion of the dental treatment.
Review results: This systematic review and meta-analysis has been registered at the International prospective register of systematic reviews—PROSPERO—CRD42021247586. The systematic review was conducted in accordance with the Preferred Reporting Items in Systematic Review and Meta-Analysis (PRISMA) guidelines. Electronic databases [PubMed (MEDLINE), COCHRANE Library, EMBASE, EBSCO host, and Google Scholar database] were searched for corresponding references up to 2021. Observational cross-sectional studies comparing two different dental anxiety scales were selected for this systematic review. Search strategy generated 500 articles out of which 13 studies included in qualitative synthesis and only 7 studies were taken for quantitative synthesis. Among these seven studies, five studies compared FIS and VPT scales, two studies compared RMS, FIS, and VPT scales. Results of meta-analysis showed that an overall mean difference of dental anxiety between VPT and FIS scales was 0.11 (95% CI: 0.26–0.48), RMS and FIS scales was 0.05 (95% CI: 0.40–0.50), RMS and VPT was 0.27 (95% CI: 0.80–0.27) in the investigated population.
Conclusion: No statistically significant difference was noted in all comparisons suggesting that all these scales are at par in assessing anxiety levels in pediatric population.
Clinical significance: The projective scales Raghavendra, madhuriu, sujata pictorial scale (RMS), Facial image scale (FIS), and Venham’s picture test (VPT) can be a pragmatic tool in assessing children’s dental anxiety.
Keywords: Children, Dental anxiety, Dental anxiety scales, Reliability.
INTRODUCTION
Anxiety is a human emotion involving behavioral, affective, and cognitive responses to the perception of danger.1 The knowledge and understanding of anxiety not only lays the foundation of our ability to provide the best possible care for children but more importantly allow us to establish a healthy and long-term relationship with them.2 Dental anxiety is a universal phenomenon that affects people of all ages across different countries. The condition negatively impacts oral health-related quality of life in children, adults, and may also impose a substantial burden to society.1,2 The etiology of dental anxiety is multifactorial, hence there is no monotherapy for management which is a significant barrier to seeking and receiving dental care.3 Furthermore, dentists perceive anxious patients as more difficult to deal with and treating people with dental anxiety require more time. In addition, anxious patients usually delay dental treatment and routinely miss dental appointments, which can lead to more complex treatment needs.4 Children with high levels of dental anxiety have increased numbers of decayed, missing and filled tooth surfaces compared with low levels of dental anxiety. Certain dental procedures do trigger dental anxiety like needles, drills, or eugenol smell.3,4 Prevalence of dental anxiety in children and adolescents ranges from 5.7 to 20.2%. The associated factors of dental anxiety such as age, sex, cultural context, socioeconomic status, presence of dental caries, history of toothache, and previous dental treatments.5 Children with high dental anxiety have neglected oral healthcare which will lead to dental problems like dental caries, periodontal diseases, and poor oral hygiene. Furthermore, underlying dental anxiety will make the children uncooperative, dental treatment a difficult one and challenging for pediatric dentist. Proper evaluation of the patient and identifying their source, level of anxiety can enable the pediatric dentist in deciding proper strategies to manage. Additionally, dental anxiety prevalence estimates may be influenced by methods used to assess it. For a pediatric dentist it is of utmost important to assess anxiety levels of a child before performing any dental treatment.6 There is a large pool of multiitem self-report scales and single-item questionnaires with result interpretation that can be used to measure dental anxiety in children and adolescents.5,6 Various methods (Nonprojective method and Projective method) have been used in literature for the assessment of dental anxiety. Nonprojective methods such as self-reporting questionnaires such as Corah’s dental anxiety survey and modified Corah’s dental anxiety survey.7 Projective methods utilize picture tests such as Venham’s pictorial test (VPT), facial index scale (FIS), RMS Scale, RMS-PS, Animated Emoji Scale, Chotta Bheem—Chutki scale assess trait anxiety. Though there have been numerous scales enlisted in the literature to assess dental anxiety, all having their own advantages and disadvantages with age appropriateness, creating pediatric dentist in a stage of dilemma to select appropriate scales to assess children’s dental anxiety before performing a dental treatment. Therefore, there is a need to have a collective literature describing dental anxiety scales in one frame.
Thus, this systematic review and meta-analysis is planned to throw a light on various dental anxiety scales available in the literature and to know their effectiveness. “Objectives of the present study are to assess various available dental anxiety scales used in children and their effectiveness of different projective dental anxiety scales used in children.”
MATERIALS AND METHODS
Protocol Registration and Review Reporting
This systematic review and meta-analysis has been registered at the international prospective register of systematic review—Prospero CRD42021247586. This review follows the guidelines of Preferred Reporting Items in Systematic Review and Meta-Analysis (PRISMA) (Flowchart 1).
Flowchart 1: PRISMA flowchart explaining the synthesis of the data for systematic review
Focused Research Question
What are the most common Dental Anxiety Scales used in Pediatric Dentistry and what is the efficiency of Facial Image Scale, Venham’s Picture Test, and RMS in Pediatric Dentistry?
Eligibility Criteria
We use the PICO format, where in population (P), children of age group 3–15 years, no intervention applied, comparison between types of anxiety (Facial Image Scale, Venham’s Picture Test and RMS) and outcome (O) anxiety levels.
Types of studies used for this meta-analysis were observational cross-sectional studies.
Inclusion Criteria
Observational cross-sectional studies comparing different dental anxiety scales.
Studies on children of age group 3–15 years which are published in English language only.
Reason for Exclusion
Studies which did not evaluate primary or secondary outcome and published in languages other than English and not related to the topic of interest were excluded from this systematic review. Also literature reviews, letter to editors, abstracts presented at conference, and book chapters were excluded.
Search Strategy
The literature search was done using computerized data base [PubMed (MEDLINE), COCHRANE Library, EMBASE, EBSCO host, and Google Scholar database] for corresponding references up to 2021. The following terms were used in our search strategy: “dental anxiety” OR “dental anxiety scales” OR “dental anxiety in children” OR “dental anxiety scales used in children” OR “anxiety scales used in pediatric dentistry” OR “Dental fear and dental anxiety scales”. The reference list of identified studies was manually searched to find any articles missed during the initial search.
Data Collection Process
Two independent reviewers performed the selection of the articles in two phases. In phase one, both the reviewers performed searches of titles and abstracts based on eligibility criteria independently. In case of discrepancies a consensus decision was taken by third evaluator, and then articles were included in the systematic review. In phase two, the same reviewers performed full text evaluation of the preselected articles for determining eligibility and extraction of relevant information.
Data Extraction
Two reviewers extracted the following data from the selected articles: author(s), year of publication, study design, aim of the study, population size and age, dental anxiety scales used, outcome (Table 1).
| SI. No | Author, year | Study design | Settings | Population size | Age | Intervention | Mean DA scores |
|---|---|---|---|---|---|---|---|
| 1 | Buchanan and Niven, 2002 | Observational cross-sectional study | Hospital-based study | 100 (T) 50 (M) 50 (F) |
3–15 years | (FIS) facial image scale (VPT) venham picture test | FIS—2.2 VPT—1.4 |
| 2 | Buchanan et al., 2005 | Observational cross-sectional study | Study setting in school | 241 (T) SFP 52 (F) 48 (M) MDAS and DFSS 120 (F) 120 (M) |
4–10 years | (SFP) scale of protective factors (MDAS) modified dental anxiety scale (DFSS) dental fear schedule subscale | SFP—18 |
| 3 | Dogan et al., 2006 | Observational cross-sectional study | Hospital-based study | 258 (T) 133 (M) 125 (F) |
8–12 years | (CDAS) corah's dental anxiety scale (FIS) facial image scale (ComDAS) combined dental anxiety scale | C-DAS—10.8 Com-DAS—11.6 |
| 4 | Howard and Freeman, 2007 | Observational cross-sectional study | Hospital-based study | 287 (T) 191 (F) 96 (M) |
8–10 years | (MCDASf) modified child dental anxiety scale with faces | |
| 5 | Krishnappa et al., 2013 | Observational cross-sectional study | Hospital-based study | 52 (T) 28 (M) 28 (F) |
6–12 years | (FIS) facial image scale (VPT) venham picture test | FIS—2.9 VPT—2.8 |
| 6 | Esa et al., 2015 | Observational cross-sectional study | Study setting in school | 87 (T) 40 (M) 47 (F) |
5–12 years | (MCDASf) modified child dental anxiety scale with faces (CFSS-DS) schedule dental subscale | MCDASf—21.7 CFSS-DS—37.5 |
| 7 | Shetty et al., 2015 | Observational cross-sectional study | Hospital-based study | 102 (T) 59 (M) 43 (F) |
4–12 years | RMS raghavendra, madhuriu, sujata pictorial scale (VPT) venham picture test (FIS) facial image scale | |
| 8 | Howard et al., 2017 | Observational cross-sectional study | Study setting in school | 287 (T) 191 (F) 96 (M) |
8–10 years | (MCDASf) modified child dental anxiety scale with faces (CFSS-DS) schedule dental subscale | |
| SI. No | Author, year | Study design | Settings | Population size | Age | Intervention | Mean DA scores |
| 9 | Sadana et al., 2017 | Observational cross-sectional study | Hospital-based study | 100 (T) 61 (M) 39 (F) |
4–12 years | CBC VPT FIS | CBC (M)—2.4 (F)—2.5 VPT (M)—3.8 (F)—3.9 FIS (M)—2.5 (F)—2.7 |
| 10 | Shetty et al., 2018 | Observational cross-sectional study | Study setting in school | 94 (T) 49 (M) 45 (F) |
12–15 years | MDAS RMS-TS |
|
| 11 | Fathima et al., 2018 | Observational cross-sectional study | Hospital-based study | 50 (T) 25 (M) 25 (F) |
5–12 years | FIS VPT |
FIS—2.7 VPT—2.6 |
| 12 | Setty et al., 2019 | Observational cross-sectional study | Hospital-based study | 102 (T) 52 (M) 50 (F) |
4–14 years | Animated emoji scale (AES) VPT FIS |
AES—1.7 FIS—1.9 VPT—1.5 |
| 13 | Oliveira et al., 2020 | Observational cross-sectional study | Hospital-based study | 30 (T) 15 (M) 15 (F) |
4–9 years | Modified (VPT) RMS-PS FIS |
Quality Assessment
The methodological quality of the included studies was assessed by using the Appraisal tool for Cross-sectional Studies (AXIS tool) for observational cross-sectional studies. The AXIS tool consisted of 20 components. A detailed explanatory document was also developed with the tool, giving expanded explanation of each question and providing simple interpretations and examples of the epidemiological concepts being examined in each question to aid nonexpert users.
Statistical Analysis
A meta-analysis was performed with the aid of review manager (Revman 5.4 software). The effect size estimated and reported as the mean difference (MD) and 95% confidence interval (CI) was calculated. A p value <0.05 was considered indicative of a statistically significant result. We used a randomized effect model to address heterogeneity. The I2 index was used to assess statistical heterogeneity.
RESULTS
We followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We also followed the recommendations of the Meta-analysis of Observational Studies in Epidemiology for the report of this systematic review.
Study Selection
Executing the search strategy generated 500 articles. After removing 120 duplicate articles, abstracts of 380 articles were viewed. On the basis of the exclusion criteria, we excluded 250 articles from the database and 90 from the gray literature after reviewing titles and abstracts, resulting in 40 articles for full-text evaluation. Out of these 40 full texts 13 studies met eligibility criteria which were taken for systematic review. Of these, only seven articles were retained for meta-analysis. Publication bias was not found in any of the analysis.
Study Characteristics
Table 1 describes the main characteristics of the studies which are included in the review. All included studies were observational cross-sectional studies, having full texts articles published in the English language till January 2021. The sample size ranges widely from 60 to 200 participants. Children’s age ranged from 3 to 15 years. Summary of available dental anxiety scale is provided in Table 3.
| Scale | Year of first publication | Age range | Items | Reliability | Limitations |
|---|---|---|---|---|---|
| VPT | 1979 | 3–18 | 8 pictures/children do not read questions or responses | Assessed | The figures on the cards are all male, this may present problems when the young patient is a girl |
| MCDAS | 1998 | 8–15 | 8 questions with 5 responses for each question | Assessed | Issues with how patients perceive the faces relate to their anxiety status, with evidence to suggest that face numbers 1, 2, and 3 may be seen as a relaxed response, while faces 4 and 5 an anxious response |
| FIS | 2002 | 3–18 | Row of 5 faces ranging from 1 to 5 | Assessed | Single item measure which may make it difficult to identify the construct of anxiety being measured |
| DAS | 2002 | 5 | Two sets of 12 clinical pictures with 4 face responses for each picture | Assessed | Cannot be used for children above 5 years of age |
| SFP | 2005 | 4–11 | 5 computerized questions with 7 face responses for each question | Assessed | The accuracy of the results could be affected by the use of seven faces |
| MCDASf | 2007 | 8–12 | 8 questions with 5 face responses for each question | Assessed | |
| RMS | 2015 | 4–12 | Row of 5 faces for boys and girls ranging from 1 to 5 | ||
| Chotta Bheem–Chutki Scale | 2016 | 4–12 | 2 cards For boys, Chotta Bheem cartoon and for girls, Chutki cartoon |
||
| Animated Emoji Scale (AES) | 2019 | 4–14 | 5 graphic of animated emoji faces The scale had scores from 1 (very happy emoji) to 5 (very unhappy emoji) |
Quality of Studies
Tables 2A and B show quality assessment of scientific evidence in chosen articles as per Axis tool.
| Buchanan and Niven, 2002 | Buchanan et al., 2005 | Dogan et al., 2006 | Howard and Freeman, 2007 | Krishnappa et al., 2013 | Esa et al., 2015 | Shetty et al., 2015 | Howard et al., 2017 | Sadana et al., 2017 | Shetty et al., 2018 | Fathima et al., 2018 | Setty et al., 2019 | Oliveira et al., 2020 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Introduction | |||||||||||||
| 1. Were the aims/objectives of the study clear? | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Methods | |||||||||||||
| 2. Was the study design appropriate for the stated aim(s)? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 3. Was the sample size justified? | Yes | No | No | Yes | No | No | No | No | Yes | No | No | No | No |
| 4. Was the target/reference population clearly defined? (is it clear who the research was about?) | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 5. Was the sample frame taken from an appropriate population base so that it closely represented the target/reference population under investigation? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Buchanan and Niven, 2002 | Buchanan et al., 2005 | Dogan et al., 2006 | Howard and Freeman, 2007 | Krishnappa et al., 2013 | Esa et al., 2015 | Shetty et al., 2015 | Howard et al., 2017 | Sadana et al., 2017 | Shetty et al., 2018 | Fathima et al., 2018 | Setty et al., 2019 | Oliveira et al., 2020 | |
| 6. Was the selection process likely to select subjects/participants that were representative of the target/reference population under investigation? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 7. Were measures undertaken to address and categorize non-responders? | No | No | No | No | No | Yes | No | Yes | Yes | No | Yes | No | No |
| Category | Authors |
|---|---|
| Good study | Sadana et al., 2017 |
| Fathima et al., 2018 | |
| Howard et al., 2017 | |
| Esa et al., 2015 | |
| Setty et al., 2019 | |
| Moderate study | Buchanan and Niven, 2002 |
| Dogan et al., 2006 | |
| Howard and Freeman, 2007 | |
| Krishnappa et al., 2013 | |
| Shetty et al., 2015 | |
| Shetty et al., 2018 | |
| Oliveira et al., 2020 | |
| Low study | Buchanan et al., 2005 |
Studies which scored more than 10 items criteria were considered of good scientific evidence. This criterion of fulfilling 50% or greater items of the Axis tool criteria said to be good scientific evidence study and less than 50% of Axis tool criteria said to be moderate studies and those studies which were under both the categories, i.e., good evidence and moderate studies demonstrated a very low risk of bias. In our systematic review and meta-analysis, of 13 studies 5 studies had a good methodological approaches (Sadana et al.,7 Fathima and Jeevanandan,8 Howard et al., 2017, Esa et al., 2015, Setty et al.10) and 7 studies were found to be moderate studies (Buchanan and Niven,11 Dogan et al.,12 Howard and Freeman,9 Krishnappa et al.,13 Shetty et al.,14 Shetty et al., 2018, Oliveira et al.15).
Meta-analysis Results
This meta-analysis comprises studies comparing FIS, VPT, and RMS scales. Hence seven studies which could be meaningfully pooled and their comparisons were of similar units of dental anxiety scales were included for meta-analysis.
Facial Image Scale vs Venham’s Picture Test
We performed the meta-analysis regarding the outcome measures. The analysis included five studies. A total of 295 children and 293 children were evaluated for the scales of Facial Image Scale and Venham’s Picture Test. An overall mean difference of 0.11 (95% CI: 0.26–0.48) was noted between the two scales in the investigated population (Fig. 1A). No significant difference (p value = 0.56) was noted suggesting both the scales are at par in assessing anxiety levels in pediatric population. Heterogeneity of 80% suggested variability which could be attributed to difference in age-groups and methodological differences.
Figs 1A to C: (A) Forest plot showing comparison of Venham’s Picture Test and Facial Image Scale; (B) Forest plot depicting anxiety scores of RMS and VPT scales; (C) Forest plot depicting anxiety scores of RMS and FIS scales
RMS Scale vs Venham’s Picture Test
Second analysis included three studies. A total of 209 children and 209 children were evaluated for the scales of RMS and Venham’s Picture Test. An overall mean difference of −0.27 (95% CI: 0.80–0.27) was noted between the two scales in the investigated population (Fig. 1B). Both were at the same par demonstrating equal reliability of both (p = 0.33). Heterogeneity of 86% showed variance was within high level.
RMS Scale vs Facial Image Scale
Third analysis included three studies. A total of 209 children and 208 children were evaluated for the scales of RMS and Facial Image Scale. An overall mean difference of 0.05 (95% CI: 0.40–0.50) was noted between the two scales in the investigated population (Fig. 1C). Both were at the same par demonstrating equal reliability of both (p = 0.82). Heterogeneity of 83% showed variance was within high level.
DISCUSSION
Dental anxiety in children has been a major concern for dentist for a long time. Many authors have evaluated dental anxiety levels in children using various dental anxiety scales.8,10,12,13,16–19 In an effort to more accurately assess anxiety levels in children, pediatric dentists typically utilize scales, which are particularly designed for use with children.14 The first developed pictorial scale was Venham’s Picture Test given by Venham and Gaulin-Kremer19 in which children are presented with eight pairs of pictures, each depicting cartoon boys in contrasting moods.3 Though this scale is the oldest and most widely used, it posed certain drawbacks like the figures on the cards are all boys; this may present problems when the young patient is a girl. Also, the scale is more time-consuming, making it difficult to use in very young patients.12 Further in this field, research on developing newer scales led to the development of many pictorial scales. Facial Image Scale given by Buchanan and Niven11 is quick and easy to administer scale, takes less time to record dental anxiety of a child, and the score is simply a reflection of the face chosen. It comprises a row of five faces ranging from very happy to very unhappy.20 In FIS, young children often face difficulties in interpreting the drawings of facial expressions.4 RMS-Pictorial scale given by Shetty et al.14 consists of a row of five faces which ranges from very happy to very unhappy. A photocopy of the scale was shown to the child and he/she was asked to choose one among the five faces according to how they feel at that moment in the dental clinic.10 Narkey et al. in 2012 and Porritt et al.2 did a systematic review on measures used to assess dental anxiety of children and they stated that there is no scale that can be considered as a gold standard, and there is a need for further development of an anxiety scale with a cognitive component for children.21 The above-mentioned systematic reviews have been done a decade ago; many newer scales would have been developed since then and also till date no meta-analysis has been performed on this particular topic. Thus, we planned this systematic review and meta-analysis looking into the need arisen from the previous systematic reviews and also adding different newer dental anxiety scales. So, in the present study, we analyzed commonly used dental anxiety scales available in the literature till January 2021.8,10,13,17–19 From the literature search 13 studies were included in qualitative synthesis and 7 studies were included in quantitative studies. These studies had enough data to be included in the meta-analysis which were comparing FIS VPT and RMS with good methodological approach. Axis tool instrument given by Downs and Black was used to assess the quality of studies. Comparative studies of pictorial scales like Venham’s Picture Scale, Facial Image Scale, and RMS Scale were selected for meta-analysis. And our results showed that the mean difference of dental anxiety between VPT and FIS was 0.11 (95% CI: 0.26–0.48) with p value 0.56, RMS with FIS was 0.05 (95% CI: 0.40–0.50) with p value 0.82, and RMS with VPT was 0.27 (95% CI: 0.80–0.27) with p value 0.33 which is statistically not significant. So, our results are suggesting that most commonly employed scales in pediatric dentistry are VPT, FIS, and RMS; also it can be stated from our meta-analysis that all three scales are equally effective in assessing dental anxiety of children.
CONCLUSION
Dental anxiety of children is challenging for pediatric dentist as well as for clinician. An accurate assessment of dental anxiety is necessary, not only to determine its prevalence but also to overcome the problems associated with individual diagnosis and planning an appropriate treatment. Thus, from this systematic review and meta-analysis, we conclude that most commonly employed projective scales in pediatric dentistry are Venham’s Picture Test, Facial Image Scale, and RMS scales. All these three scales are equally effective in assessing children’s dental anxiety. This paper is throwing a light for pediatric dentist to choose appropriate dental anxiety scales to assess children’s anxiety prior to dental treatment thus making dental treatment hassle-free and also these findings can be utilized by academician, clinician as well as psychologist to select the right dental anxiety assessment tool for their intended purpose.
RECOMMENDATIONS
Projective dental anxiety scales can be a pragmatic tool in assessing children’s dental anxiety.
The most commonly used dental anxiety scales are Facial Image Scale, Venham’s Picture Test, and RMS.
Facial Image Scale, Venham’s Picture Test, and RMS are equally effective, easy to administer in children, and are less time-consuming.
Facial Image Scale, Venham’s Picture Test, and RMS can be employed by Clinician and Researcher in assessing dental anxiety of children.
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