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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 60-64

Psycho-social correlates of dental anxiety and its association with caries experience in 12-16-year-old school going children in Southern India

1 Department of Public Health Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth (An Institution Deemed to be University), Vadodara, Gujarat, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
3 Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, Australia
4 Pediatric and Preventive Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth (An Institution Deemed to be University), Vadodara, Gujarat, India

Date of Submission23-May-2021
Date of Decision26-Jul-2021
Date of Acceptance29-Sep-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Sweta Singh
Department of Public Health Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth (An Institution Deemed to be University), Vadodara - 391 760, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_85_21

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Introduction: Dental anxiety causes a decrease in population addressability to the dentist with antagonistic consequences for long-term oral health. Assessment of behavioural factors that correlate with dental anxiety is important for the accurate evaluation of dental fear. Its diagnosis in childhood is important for establishing therapeutic management strategies to reduce anxiety and promote oral health. Materials and Methods: A sample of 289 children of ninth and tenth grades from two public and two private schools of Udupi town was drawn. Two-stage sampling was used for the enrolment of students. A pre-tested self-administered questionnaire was used for the collection of data on psychological aspects, socioeconomic background and health behaviours. Dental anxiety was assessed using a translated version of the modified dental anxiety scale (MDAS). Oral examination was done for the assessment of dental caries using the decayed, missing, filled teeth index. Results: Students from public schools showed a significantly high prevalence of dental anxiety and also higher scores. Dental phobia was significantly more in children from public schools. Female gender, lesser brushing frequency, fewer previous dental visits and lower socioeconomic status were significantly associated with higher dental anxiety levels. In addition, the caries experience was significantly higher in children from public schools. Conclusion: Socioeconomic background and social environment in the school play an important role in overcoming dental anxiety and practising healthy behaviour and therefore should be considered to break the vicious cycle of dental anxiety and poor dental health.

Keywords: Children, dental anxiety, dental caries, public schools

How to cite this article:
Singh S, Acharya S, Bhat M, Chakravarthy P K, Kariya P. Psycho-social correlates of dental anxiety and its association with caries experience in 12-16-year-old school going children in Southern India. Adv Hum Biol 2022;12:60-4

How to cite this URL:
Singh S, Acharya S, Bhat M, Chakravarthy P K, Kariya P. Psycho-social correlates of dental anxiety and its association with caries experience in 12-16-year-old school going children in Southern India. Adv Hum Biol [serial online] 2022 [cited 2022 Aug 15];12:60-4. Available from: https://www.aihbonline.com/text.asp?2022/12/1/60/334590

  Introduction Top

It is known that the percentage of unmet treatment needs in both primary and permanent teeth in children is high.[1] Several factors may contribute to the high percentage of these unmet treatment needs. One is believed to be the use of rotary equipment and frequent administration of local anaesthesia. Both the bur and dental injection are considered the two main fear-provoking stimuli.[2] It is no surprise, therefore, that the use of restorative and surgical treatment has a high potential for triggering dental anxiety in many children. It is well-known that not only the dental treatment itself, but even the anticipation of such treatment could give rise to fear and anxiety in many individuals. This is due to the fact that dental treatment is often associated with the threat of pain and suffering.

Dental anxiety can serve as a cause for irregular dental attendance, delay in seeking dental care or even avoidance of dental care. Dental anxiety would not only have detrimental effects on the individual, but also the management of such patients poses a great challenge.

The burden of suffering of dental caries is a common phenomenon, and it cuts across all socioeconomic strata (SES). It has been revealed that the dental caries experience of 12-year-old children appears to be highest in countries with low level of primary education.[3] India is a country in transition, whose economy has grown tremendously during the last decade. The population, however, continues to suffer from the consequences of dental caries and other oral health problems. There is evidence that the prevalence, as well as the aetiology or predominant characteristics of dental anxiety, is influenced by culture.[2] Furthermore, the aetiology of dental anxiety is believed to be multifactorial, with age, gender and SES playing important roles as risk factors.[4] Hence, factors that have been identified as responsible for dental anxiety in populations from industrialised countries may not be the same for populations in developing countries like India. Therefore, there is a need to study the determinants of dental anxiety in children under the light of their socioeconomic and cultural background. This study was done with an aim to assess the correlation of dental anxiety with sociodemographic factors and dental caries in children from public and private schools. It was hypothesised that children from public schools and those from poor socioeconomic backgrounds are more likely to show dental anxiety and high caries experience.

  Materials and Methods Top

Study setting and population

In this cross-sectional study, ninth- and tenth-grade students from public and private schools in Udupi district, Karnataka, were included. A total of 289 students (155 public and 134 private) participated in the study. All the children in the sample were personally met in the classroom to explain the purpose of the study. The research protocol was reviewed by the Institutional Review Board, and ethical approval was obtained from the University Ethics Committee, Manipal (UEC/10/2017). The research was conducted in accordance with the Declaration of Helsinki.


A two-stage sampling technique was used for the enrolment of students. The list of public and private schools in Udupi town was obtained from the District Education Office. From a total of 15 schools in the Udupi cluster, two public and two private high schools were randomly selected using lottery method. Considering 95% confidence interval (CI), 5% margin of error and 77% prevalence rate of dental caries, the sample size was estimated to be 273 with a 10% non-response rate.[5] Two hundred and eighty-nine students were then selected by a simple random technique using a table of random numbers. The exclusion criteria were as follows: the presence of fixed orthodontics bands, systemic illness and currently on medication for any reason.


A pre-tested self-administered questionnaire was used for data collection. The questionnaire consisted of the following three parts:

The first part included sociodemographic correlates such as age, sex, type of school, a previous visit to the dentist, parent's education, income and occupation. The SES was inferred using the aforesaid variables with the help of the Kuppuswamy scale to divide them into upper, middle and low SES.

Dental anxiety was measured using the Kannada translation of the Modified Dental Anxiety Scale (MDAS). This self-rating instrument was introduced by Humphris et al.[6] It differs from the Corah's Dental Anxiety Scale (DAS) by including an additional question on a local anaesthetic injection. Each question has five scores ranging from 'not anxious' to 'extremely anxious' in ascending order from 1 to 5. Each question carries a possible maximum score of 5 with a total possible maximum score of 25 for the entire scale. The English version of the MDAS was translated/back-translated into Kannada/English by two bilingual individuals independently, and the conceptual and functional equivalence of the instrument was verified by colleagues at the Manipal University. Good reliability of the MDAS in terms of the inter-item correlation coefficient (Cronbach's alpha = 0.85) was determined. If a single item was removed, the Cronbach's alpha value decreased compared to its original undeleted value. The average of the inter-item correlation among the DAS items was 0.59 (range: 0.49–0.74), with no negative correlations. The corrected item-total correlations ranged from 0.67 to 0.78, and all values were above the minimum recommended level of 0.20 for including an item into a scale.[7] The Kannada version of the scale has been shown to have good validity and reliability.[8]

The two cut-off points used for MDAS score were ≥16 (corresponding to 13 of CDAS) and ≥19 (corresponding to 15 of CDAS), as determined by Humphris et al.[6] This scale was used because translated versions of it have proved to be valid and reliable measures of dental anxiety in culturally diverse populations.[2] Using Cronbach's alpha, the internal consistency of MDAS was found to be 0.89. Inter-item correlations gave Pearson's r between 0.59 and 0.92, except for item 5 of the scale (0.35–0.51) at 5% significance level.

Clinical dental examination

An oral examination to record the caries status was performed under natural daylight within the school premises. Caries was assessed using the decayed, missing, filled teeth (DMFT) index as described by the World Health Organization (WHO).[9] Before the start of the study, the researcher was calibrated at the Dental Clinic of Manipal College of Dental Sciences, Manipal, according to the WHO standards.[9] Sixty students were randomly selected for clinical re-examination. The intraclass correlation coefficient for DMFT was 0.989 (95% CI: 0.979–0.997).

Statistical analysis

The statistical analysis was done using IBM SPSS Statistics for Windows, version 23 (IBM Corp, Armonk, NY, USA). Associations between independent variables and dental anxiety were determined using the mean MDAS score. The participants were dichotomised as dentally anxious (MDAS ≥16) and not anxious (MDAS ≤15). The Chi-square test was used to test the association and compare non-parametric variables. An independent t-test was used to compare the mean MDAS scores. Spearman's correlation was used to check the correlation between sociodemographic variables and dental anxiety.

  Results Top

The mean age of the sample was 13.6 years (±0.92 years). Of the 289 children who completed the survey, 50.2% were males. The proportion of public schoolchildren (53.6%) was similar to that of private schoolchildren (46.36%). The mean ages of the public and private schoolchildren were 13.61 ± 0.87 and 14.31 ± 0.82 years, respectively. Sixteen per cent of the students were from a rural area, 58.5% from a peri-urban area and 16.6% from an urban area. Approximately 45.7% of the children brushed once daily, and the remaining 53.3% brushed more than once daily. The mean MDAS score for the total sample was 12.33 ± 4.34 [Table 1].
Table 1: Sociodemographic and socioeconomic characteristics of the children from public and private schools

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Only 31.6% of the public schoolchildren had previously visited a dentist compared to 82.8% of the private schoolchildren. Only 66.5% of the children from public schools brushed their teeth daily compared to 85.8% of private schoolchildren. Almost 85.8% of the children of a private school were from the upper socioeconomic class compared to 1.3% of public schools.

The prevalence of dental anxiety was 40% in public schoolchildren when compared to 7.5% in private schoolchildren (MDAS ≥16). Nearly 14% of the public school respondents were extremely anxious or 'phobic' (MDAS ≥19), whereas that of private schools was only 1.5%. The mean MDAS score of the public schoolchildren was 13.63 ± 4.81, and that of private schoolchildren was 10.82 ± 3.12. The difference in the scores was statistically significant [Table 2].
Table 2: Dental anxiety level in children from public and private schools

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When the MDAS scores were compared in relation to the type of treatment, the highest score was observed for injection in both the categories of schoolchildren and both the gender. It was followed by drilling, being the second most common anxiety-provoking treatment procedure, followed by waiting in for treatment and scaling. The public schoolchildren had significantly higher anxiety levels for all treatment procedures except for injection. This held true for both genders, though the mean scores were higher in the case of females for all treatment procedures. Girls scored higher on anxiety when compared to boys [Table 3].
Table 3: Comparative levels of dental anxiety in children from public and private schools in relation to various treatment procedures

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It was found that public schoolchildren had higher DMFT (2.10 ± 1.80) than that of private schoolchildren (1.65 ± 1.74). The mean DT and DMFT were significantly higher, and the mean FT was significantly lower in public schoolchildren.

Children who had previously visited the dentist more times from higher SES and those who brushed their teeth more times reported lesser dental anxiety levels (P < 0.005). However, there was no correlation found between caries experience and dental anxiety [Table 4].
Table 4: Correlation between sociodemographic and socioeconomic factors and dental anxiety

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Caries experience was found to be significantly higher in public schoolchildren. This difference was found significant with respect to DT and DMFT scores. The FT score was significantly higher in children from private schools [Table 5]. On testing the correlation between dental caries and MDAS scores, a significant correlation was found only with DT scores.
Table 5: Dental caries experience in public and private schoolchildren

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  Discussion Top

The present study found that both the prevalence and mean anxiety scores were higher among public schoolchildren. In addition, the prevalence of 'dental phobia' was higher in public schoolchildren. SES, previous dental visits and frequency of brushing were found to be associated with dental anxiety.

Female students from both schools showed higher MDAS scores than those of boys, which is in line with previous studies.[10],[11] Gao et al. have reported no correlation between boys and girls.[12] However, the gender difference has been supported in many other studies.[13],[14],[15] It has been suggested that women are more expressive of their fear, whereas men are stoic. Whether they are indeed more dentally anxious or whether a bias in reporting exists cannot be answered with the present evidence.

The present study has shown that irregular dental visits are a significant predictor of higher dental anxiety, which is in accordance with previous studies and is rather self-evident.[16],[17] However, Kothari and Gurunathan reported no association of previous dental visits and SES with dental anxiety.[18] A higher proportion of private schoolchildren attended dentist regularly and reported lesser dental anxiety levels than those of public schoolchildren who were not regular visitors to the dentist. In addition, students brushing their teeth more frequently showed lesser dental anxiety. However, the difference found in the present study may be related to the variation in the perception of oral health in both the school systems and not solely on socioeconomic background. In schools, children can have their perception of health-related matters, including visits to the dentist, are influenced positively by their peers who attend the dental clinic regularly and have developed a positive attitude towards dental care. Because a higher proportion of children in a public school visit the dentist only in an emergency, the likelihood of experiencing pain and becoming fearful is greater in this group than that in the other group.

In the present study, the 'crossover' effect between the two socioeconomic groups (public vs. private) has a very limited impact. The mean MDAS score of public schoolchildren (low to middle SES) was significantly higher than that of private schoolchildren (high socioeconomic group). This is in accordance with previous studies, which reported that lower social class groups have higher dental anxiety.[17]

When dental anxiety was related to the type of treatment, dental anxiety to the sight and sensation of the needle was highest, followed by sight, sound and feeling of the drill. Similar findings have been reported in previous researches.[19] In general, public schoolchildren have significantly higher mean values of dental anxiety when compared to private schoolchildren. Such variation of dental anxiety among public and private schoolchildren was statistically significant for all items except for the sight of a needle.

The caries prevalence was found to be significantly higher in public schoolchildren in the present study. This suggests a close relationship between overall caries prevalence and dental anxiety. The model of the vicious cycle of dental fear, postulated by Armfield et al. in 2007, hypothesised that 'people with high dental fear are more likely to delay treatment, leading to more extensive dental problems and symptomatic visiting patterns which feedback into the maintenance or exacerbation of the existing dental fear'.[20] The findings raise the question about the direction of causality between dental anxiety and caries experience if, indeed, the relationship is causal. Further studies are necessary on whether individuals with high caries experience require more invasive dental treatment and consequent negative dental experiences lead to dental anxiety or dentally anxious individuals avoid dental treatment and neglect oral self-care, thereby leading to their high caries experience. Caries experience has been found to be significantly associated with dental fear and anxiety in some previous studies.[21],[22]

Taking into account the substantially high prevalence in the level of dental anxiety among the children from public schools, health measures should be directed towards promoting dental literacy, increasing knowledge on the prevention of dental diseases and motivating good oral health habits in children and young adults.[17]

  Conclusion Top

It can be concluded that children in public schools present higher anxiety for dental treatment and also higher caries experience. In addition, socioeconomic background, poor oral health practises and lesser dental visits were also found to have a significant correlation with dental anxiety. This vicious circle leads to poorer oral health in these children.


This being a cross-sectional study, no causal relationships on the association between dental anxiety and the factors associated can be determined. The study may be limited by the fact that schools from only one only cluster of districts were selected, limiting the generalizability of the results. Although the MDAS scale has established and good psychometric properties, it has been argued that the Corah's DAS does not consider the theoretical structure of dental anxiety and that its response categories are not mutually exclusive.[23] Information on oral health behaviours, SES, general health and psychological health in the present study was self-reported; thus, the possibility of social desirability bias due to under- or over-reporting cannot be ruled out.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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