Dental anxiety and the status of first permanent molars in 11 and 15 years old children

Summary Introduction Fear of dental procedures is one of the main reasons for oral health neglect. The first permanent molars are functionally very important. Dental anxiety may compromise their health as well as the health of all other teeth. The aim of the study was to determine dental anxiety level and the status of first permanent molars in healthy school aged children. Methods This study included 105 students, 11 and 15 years of age, from two elementary schools in Foca (Bosnia and Herzegovina). Dental Anxiety Scale (DAS), questionnaire was used to determine the level of dental fear in patients. The status of first permanent molars was recorded using Klein-Palmer DMFT (decayed, missing, filling teeth) system. The number of healthy first permanent molars (with or without sealant) was registered as well. Results More than one third of respondents involved in this study (33.3%), suffered from severe dental anxiety (DAS = 13–20 points). Statistically significant difference in answers to questions was not observed between respondents of different age but higher level of the fear was registered in girls compared to boys (p < 0.05). Less than 50% of all examined first permanent molars were healthy and sealed fissures were recorded in 9.4% of them. The percentage of decayed molars was about 11%, 7% extracted and 35% filled. Conclusion Application of prophylactic measures is beneficial for dental health preservation. They are pain free and can be used to minimize fear by establishing dentist-patient relationship based on confidence.


INTRODUCTION
In the era of modern dentistry when dental procedures are completely painless, a fear of dentist still exist in children and adults. This fear is one of the main reasons for oral health care neglect. Under the concept "fear of dentist, " it is possible to distinguish dental anxiety, dental fear and dental phobia [1].
Dental anxiety is the mildest form of fear of dentist, and is characterized by patients' excitation and a sense of control loss [2]. Dental fear presents an active response to a known danger, that is object or situation, and occurs in people who have already had unpleasant dental experience and expect that this will inevitably happen again [3]. Dental phobia is the most intensive fear of dentist and presents narrowly defined diagnosis made by psychologists and psychiatrists. This mental disorder is characterized by a pronounced fear or avoidance of a particular object or situation that significantly interfere with the function or causes considerable emotional stress of a patient [3,4]. Fear of dental procedures can cause serious health problems, as avoiding dental visits may lead to complications of diseased oral tissues [5]. Fear of dental intervention is in high fourth rank in relation to other situations that cause fear. It can be the cause of so-called vicious circle, when dental fear leads to dental visits delay, which may further increase present difficulties and already present fear [6]. Otherwise, fear is a subjective category that is not comarable between the two persons. Clinically, it is manifested by dilated pupils, dry mouth, rapid breathing, tachycardia, excessive sweating, cold hands. All of these clinical signs are result of increased adrenocortical hormone -adrenaline, and clinical picture is dominated by the effect of the sympathetic nervous system [7].
The first permanent molars are, in most cases, the first permanent teeth that erupt in children [8]. These functionally important teeth in humans are significant indicators of permanent teeth caries presence as well as preventive prophylactic and therapeutic measures applied [9]. Therefore, the status of first permanent molar health to some extent may be an indirect indicator of dental fear in patients.
The aim of the study was to determine dental anxiety level and the status of first permanent molars in healthy school aged children.

MATERIALS AND METHODS
The study involved pupils from two elementary schools in Foca (Bosnia and Herzegovina), aged 11 and 15 years. Parents of the respondents were informed in details about the nature and the course of the study and gave consent for the inclusion of their children in the study. This study was conducted according to the recommendations of the Helsinki Declaration and the principles of Good Clinical Practice.
Dental Anxiety Scale (DAS) questionnaire was used for to assess the level of fear in patients. The questionnaire was prepared according to the Corah's Dental Anxiety Scale that was published in 1969 and considered to be valuable and reliable indicator in clinical trials [10]. The questionnaire consists of four questions about the situations related to dental treatment and every question has 5 answers. The answers were scored according to the fivepoint Likert scale (a = 1, b = 2, c = 3, d = 4 and e = 5), and the level of anxiety was calculated from the sum of points: -Between 4-8 -no anxiety -Between 9-12 -moderate anxiety -Between 13-14 -high anxiety -Beetween 15-20 -severe anxiety Clinical examination was performed in all subjects. Dental examinations were performed in schools using standard dental instruments, dental explorer and mirror. The status of first permanent molars was recorded using Klein-Palmer DMFT (decayed, missing, filling teeth) system [11]. Also, the number of healthy first permanent molars (with or without sealant) was recorded, while other permanent teeth were not taken into consideration.
Data were presented by standard methods of descriptive statistics (percentage, mean (X), standard deviation (SD)). Differences between groups were tested using Mann-Whitney U-test and t-test. SPSS 11.5 for Windows Statistical Program was used for data analysis.

RESULTS
The study involved 105 subjects: 52 girls (49.4%) and 53 boys and (50.5%). The average age of female respondents was 13 ± 1.4 and 13 ± 1.8 for male subjects. The distribution of subjects by gender, age and the frequency of dental visits is presented in Table 1.
More than one third of involved respondents (33.3%, DAS = 13-20 points) had high and severe level of dental anxiety. In almost 40% of respondents fear of dental procedures was not found (DAS = 4-8 points). No statistically significant differences in answers to questions were observed between respondents of different age but higher value of the fear was present in girls (21,9%, DAS = 13-20 points) than boys (11,4%, DAS = 13-20 points). This difference was statistically significant (p < 0.05). Table 2 shows detailed relationship between anxiety of dental procedures and behavior of subjects given by the Corah's Dental Anxiety Scale questionnaire.
More than 40% of children go to regular dental checkups several times a year. On the other hand, about 5% of children visited a dentist only once in several years.
However, children who visited dentist once a year or less experienced high degree of dental anxiety as confirmed by statistically significant difference (p < 0.05) compared to the children without fear who practice regular dental visits. Less than 50% of the first permanent molars were completely healthy in both age groups. Percentage of sealed fissures in healty first permanent molars was 9.4%, the percentage of decayed molars was almost 11%, extracted almost 7%, while the percentage of filled was around 35% (Graph 1). 34 children had all four first permanent molars completely healthy, while in 4 children all four molars have already been extracted. The most frequently extracted tooth was lower right first molar. Eleven years old children had more healthy first permanent molars compared to fifteen years olds, however, the difference between the groups was not statistically significant. Also, boys had higher number of healthy molars, as well as higher percentage of filled teeth compared to girls, but the difference was not statistically significant.

DISCUSSION
The results of the current study indicate the presence of high level of dental anxiety and high prevalence of first permanent molars decay. Therefore, the fear of dental procedures is an important problem in everyday practice, not only in pediatric dentistry but in other fields of dentistry as well. Studies that have investigated this issue indicate that dental anxiety is present at all ages and is not related to gender [12][13][14][15].
No anxiety was found in 39% of subjects of this study, moderate anxiety was identified in 27.6% of subjects while high and severe anxiety were registered in more than one third of subjects (33.2%). These results are comparable to similar studies. The study done by Alak at al. (2012) indicated 34% of children, 11 to 15 years of age, had high and severe dental anxiety while 32.4% children showed no fear [12]. For adult subjects, studies showed high and severe dental anxiety present in almost 30% of participants aged 18-82 years while 34.6% of subjects showed no dental anxiety [14].
Dental fear negatively impacts both patients and dentists. It can be avoided or minimized by establishing good dentist-patient relationship based on confidence or by implementation of good introduction about upcoming dental intervention [16]. Also, in the age of information systems, patient frequently firstly consults newspapers and Internet what could also result in additional negative outcomes due to incorrect information [17]. It is therefore necessary for a dentist to provide proper information, attract sympathy of patients and gain their trust.
Respondents included in the current study were eleven and fifteen years of age, a period of intense shifts of deciduous and permanent teeth, as well as completion of permanent dentition. Dental anxiety was equaly present among the respondents. The frequency of dental visits was significantly lower in anxious patients. It has been proven that children who go to the dentist once a year or less, have higher dental anxiety level than those who visit dentists twice a year. The results also showed higher prevalence of dental anxiety in girls and that is in accordance with other studies that also reported women experience greater fear of dental procedures [12,18]. This can be explained by the fact that females are more prone to having higher levels of neuroticism as well, and anxiety is positively associated with neuroticism [19].
Time spent in the waiting room proportionally increases the level of anxiety. Despite relatively frequent occurrence of dental anxiety, dentists often do not have enough understanding and knowledge about the psychological approach to such persons [17]. However, due to increasingly serious legislation treatment of this phenomenon, and the threat of lawsuits, it is necessary to develop special techniques of communication [17]. According to Hmudu (2009) there are four different fear triggers that patients respond to differently, and can be displayed as a "Rule 4 S" [20]: • Sights -visual experience (needles, drills) • Sounds -sounds (slow speed handpiece, high speed handpiece) • Sensations -feelings (vibrations) • Smells -odors (different dental materials) The results of our study indicated that more than half of all examined first permanent molars had some of DMFT components. Percentage of teeth with sealed fissures (9.4%) was relatively small, and that is one of the fear parameters as fissures sealing process is fast, easy, completely painless and therefore suitable for massive ap- plication and fear elimination. Our study also indicated the prevalence of first permanent molars decay increased with age of respondents as previously indicated by other authors [21,22]. Also, due to strong prevention programs, there has been a constant decline in permanent teeth decay prevalence in developed countries [9]. However, in our region, the percentage of extracted first permanent molars continuously increases with the age of respondents. Out of the total number of inspected teeth in this study, about 7% of them have already been extracted, which is devastating fact as the first permanent molar has very important functional significance [8] and its extraction may have many negative consequences [22]. The prevalence of tooth decay in all ages was higher in girls, but without significant difference in comparison to boys.
Some studies showed that socio-economic status and education level might impact the prevalence of dental anxiety in the population [6,23]. The highest levels of anxiety are registered in adolescents, which are mainly resulted by their own bad childhood experiences or negative experiences of parents or friends [17]. Studies have shown that the average age of about 40 years, both for women and men, is when fear reduction begins. This can be explained by increased tolerance, due to more frequent and prolonged exposure to stressful situations as well as life experiences that shape behavioral characteristics of individuals [18]. Anxious patients require special attention, and DAS questionnaire can be used in dental practise as guidance in decision-making whether a dental treatment requires specific techniques such as sedation or even general anesthesia.

CONCLUSION
Dental anxiety is important reason for dental visits avoidance. It can certainly contribute to poor oral health as well as development of dental complications. Almost every third child from this study experienced noticeable dental anxiety. School age life period is most critical but also the most important for application of preventive and prophylactic measures and procedures that aim oral health preservation. The most efficient prophylactic measure for reduction of tooth decay is fissure sealant aplication.
Fissure sealant aplication is completely pain free procedure that can be used as a way to release or reduce fear in patients. Dental anxiety awareness of dentists is also essential for good communication establishment and proper approach to patient in everyday practice.