Eur Arch Paediatr Dent DOI 10.1007/s40368-014-0126-z
ORIGINAL SCIENTIFIC ARTICLE
Children’s and parents’ attitudes towards dentists’ appearance, child dental experience and their relationship with dental anxiety H. J. Tong • J. Khong • C. Ong • A. Ng Y. Lin • J. J. Ng • C. H. L. Hong
•
Received: 17 December 2013 / Accepted: 21 March 2014 European Academy of Paediatric Dentistry 2014
Abstract Aim To evaluate child and parental attitudes towards dentists’ appearance, subsequently related to a child’s dental experience and their association with child’s anxiety levels. Methods 402 parent–child pairs were surveyed using interviewer-administered questionnaires at the School Dental Service, Health Promotion Board, Singapore. Standardised pictures of models with different attires, ages, genders and ethnicities were shown to the parent–child pairs. Information on each child’s dental experience was obtained. Parental proxy was used to evaluate the children’s dental fear levels based on the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS). Results Personal protective equipment (PPE) was the attire of choice for both parents and children, followed by the paediatric coat. Formal and informal attire was least preferred by children and parents, respectively. Parents preferred female dentists to treat their child, whereas children preferred a dentist of the same gender (p \ 0.001). Parent’s and child’s preferences for the child’s dentist’s appearance were shown to be significantly different
H. J. Tong (&) J. Khong C. Ong A. Ng Y. Lin C. H. L. Hong Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, 11 Lower Kent Ridge Road, Singapore 119083, Republic of Singapore e-mail: [email protected] H. J. Tong School Dental Service Level 4, Health Promotion Board, 3 Second Hospital Avenue, Singapore 168937, Republic of Singapore J. J. Ng The Oral Care Centre, 10 Sinaran Drive, #10–17/#10–04, Singapore 307506, Republic of Singapore
(p \ 0.001). CFSS-DS scores were also significantly associated with the number of previous dental visits (p = 0.002) as well as a history of extractions (p = 0.02), but not with child’s demographics, dmft or preference for dentist’s appearance (p [ 0.05). Conclusion Regardless of child anxiety levels, the PPE followed by paediatric coats were preferred over other choices of dentists’ attire. Children tended to choose a dentist who was of a younger age, and of the same gender and ethnicity as themselves. Parents tended to choose younger, female dentists of the same ethnicity as themselves. Subjective experience of extractions, as well as multiple dental visits appeared to play a more significant role in the development of dental fear than dental caries experience per se. Keywords
Dentist attire Dental anxiety Dental fear
Background Childhood dental fear is common among children (Rantavuori et al. 2009). The estimated prevalence of childhood dental fear reported in the literature ranges from 4 to 43 % in different populations (ten Berge et al. 2002). Children are thought to be afraid of the dentist as a result of separation anxiety from their caregiver and the feeling of helplessness in a foreign environment, as well as their fear of bodily harm and corresponding perception of dental instruments as objects of pain, violence and destruction (Sharma and Sharma 1976). Differences in age, gender, personality, previous painful dental experiences, and increased general and parental dental anxiety can also account for fear in certain children (Klaassen et al. 2002). Dental fear is a major hindrance to the delivery of quality
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dental care and may become a problem for both dentists and patients. For a dentist, dental anxiety is an obstacle to good cooperation and a stress-free relationship between a patient and their dentist; whereas for the fearful patient, avoidance of dental treatment due to dental anxiety may lead to poorer oral health (Berggren and Linde 1984). Several scales that have been used to measure and assess dental fear in children, and they are broadly categorised into four groups: (1) Behaviour rating during dental visits (e.g. Frankl scale), (2) Physiological measures (e.g. pulse rate, basal skin response and muscle tension), (3) Projective techniques (e.g. children’s dental fear picture test, Modified Child Dental Anxiety Scale) and (4) Psychometric scales (Yamada et al. 2002). Of the many psychometric scales available, the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) is most frequently used for the determination of dental fear and anxiety (Cuthbert and Melamed 1982). CFSS-DS has been translated into several languages for use in different countries, and is favoured in research studies because of its ease of administration, along with good reliability and validity (ten Berge et al. 2002; Gustafsson et al. 2010), and is regarded as the ‘gold standard’ measure of the child dental anxiety inventory (Howard and Freeman 2006). A patient’s perception of a physician’s ability has been shown to be influenced by their appearance, which in turn can also affect the anxiety and comfort level of patients receiving treatment (Brosky et al. 2003). Children as young as 5 years of age have been found to be capable of forming judgments of their dentist based on his or her appearance, which in turn may influence their behaviour in the dental chair (Barrett and Booth 1994; Marino et al. 1991; Townend et al. 2000). One study evaluating the effect of dentists’ appearance found that adults generally preferred their dentists to dress traditionally (i.e. white coat) or in formal attire (Mistry and Tahmassebi 2009). However, the literature on children’s preference of attire for their dentist reports conflicting results, where some studies noted that children preferred their dentist to be in casual attire (Brosky et al. 2003; Mistry and Tahmassebi 2009), while others favoured their dentists in traditional attire (McCarthy et al. 1999; Kuscu et al. 2009). Age and gender can also affect patients’ perception of their dentist. While adults did not appear to display a significant preference with regards to the age and gender of their physicians (Kanzler and Gorsulowsky 2002; Keenum et al. 2003), children on the other hand have been found to display strong gender preference for their healthcare professional (Turow and Sterling 2004; Mistry and Tahmassebi 2009). The effect of ethnicity on patient’s perception of the appearance of their healthcare professional is also not well established. African-American patients were found to value their physician’s appearance more highly and were more
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trusting of well-dressed physicians as compared to Caucasian patients (Rehman et al. 2005). Likewise, Asian children were found to prefer physicians in white coats (Marino et al. 1991; Barrett and Booth 1994; Mistry and Tahmassebi 2009). This suggests that ethnic and cultural differences can influence both adults’ and children’s perception and hence personal preferences of their healthcare professional (Barrett and Booth 1994). Psychologists and sociologists stress the strong relationship between appearance and its effect on first impressions and interpersonal relationships. This information is important as it can help dentists better shape their practices to meet the preferences and needs of their patients. Multi-racial societies with diverse cultural and environmental influences such as Singapore may have varying perceptions of ethnicity, gender and attire as compared to western nations (Department of Statistics Singapore 2014). As such, it may be inaccurate to generalise findings of previous research for application into the local context. This study aimed to assess Singaporean children and parental attitudes towards dentists’ appearance with regards to their attire, age, gender and ethnicity. The secondary aims of the study were to explore: The association between child’s dental fear and their preferences for dentist’s appearance, and the relationship between child’s dental fear and number of treatment visits, treatment procedures, as well as decayed, missing and filled teeth in the primary dentition (dmft).
Materials and methods Ethics approval and participant recruitment Approval from the National University of Singapore Institution Review Board and the Health Promotion Board Medical Board was obtained prior to commencement of the study (NUS IRB Reference code 12-009; approval number NUS 1502). Potential participants were identified through the clinic list and approached while they were waiting for their appointment. Informed consent from the parents and child assent was obtained. Sample This was a cross-sectional observational study. The participants of the study consisted of children and their parents who attended the paediatric dental clinics at the School Dental Service, Health Promotion Board, Singapore. Recruitment was carried out from March to June 2012. The inclusion criteria were as follows: •
Adults and children who were able to understand and communicate in English or Mandarin language.
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• •
Children who were between 5 and 7 years of age (inclusive). Children who had a physical status of ASA 1 or 2 (American Society of Anesthesiologists 2014). The exclusion criteria were as follows:
• • •
Children who were cognitively disabled and unable to complete the survey independently. Children of ASA 3 and above. Children who were not accompanied by their parents.
Sample size As there were no similar studies carried out in Singapore, the sample size for this study was computed based on estimates. Aiming to detect a minimum difference of 1.123, and assuming a standard deviation of 8 on the CFSS-DS anxiety scale (range 0–75), with a of 0.05 and 80 % power, the minimum sample size needed for this study was 400 parent–child pairs.
Set 1: Evaluation of attire: photographs of a male and female model dressed in six different attires (formal, paediatric coat, scrubs, white coat, personal protective equipment, informal) were shown. Smiley faces were superimposed onto the faces (Fig. 1). Parents and children were asked to rank how they would prefer their dentist to be dressed, starting with the most preferred and the least preferred. Thereafter, they were then asked to rank the remainding four attires from most to least preferred. Set 2: Evaluation of age: photographs of paired male and female models of two distinct age groups (depicting young and senior) were shown. Participants were asked if they preferred a younger or older dentist. Set 3: Evaluation of gender: photographs of an individual male and female model were shown. Participants were asked if they preferred a male or female dentist. Set 4: Evaluation of ethnicity: photographs of paired male and female models of three different ethnicities (Chinese, Indian, and Malay), depicting the three main races in Singapore, were shown. Parents and children were asked to rank which ethnicity they would prefer their dentist to be, from most to least preferred.
Data collection Section 3: CFSS-DS Parents and children were surveyed separately using an interviewer-administered questionnaire. The parent’s questionnaire consisted of three sections, while the child’s questionnaire involved questions only from Sect. 2: Section 1: demographics, child’s medical and dental history • • •
Demographics—age, gender and ethnicity of parent and child, as well as any parental relationship to each child Child’s medical history Child’s dental history—first visit appointment (yes/no), dental treatment received (yes/no), and type of treatment received (scaling and polishing, fillings, extractions and pulp treatment) where appropriate. Information on each child’s number of previous dental visits, treatment received and caries status was verified using the electronic dental records system.
Section 2: questionnaire survey Four sets of photographs were shown to the participants. In all the photographs, facial expression, posture and hairstyle were kept as similar as possible. None of the individuals pictured in the photographs were involved in the survey or treatment process. The option for ‘‘no preference’’ was not available, thus ensuring that all participants had to make a decision among the photographs shown.
Parents were asked to determine the anxiety level of their child using the CFSS-DS and were asked to score a list of 15 questions in different domains contributing to dental anxiety based on a Likert scale ranging from 1 (not afraid) to 5 (very afraid) (Majstorovic et al. 2003). The scores were then summated to give the CFSS-DS score (range 15–75). For ease of comparison with existing studies (Gustafsson et al. 2010), a score of 38 was set as the cut-off for clinical dental fear, with a score of \38 denoting absence of clinical dental fear, and C38 indicating presence of clinical dental fear. Pre-testing of the questionnaire was conducted on 10 parent–child pairs to ensure the questions were fit for purpose, to test for ease of understanding, ambiguity, and to evaluate the workflow of the data collection process. Results obtained from the questionnaire testing were not included in the data analysis of the final study. Data was collected onto optical mark recognition (OMR) sheets, which were scanned using the Remark Office OMR software via a Kodak i2400 scanner, and converted into an Excel spreadsheet (Microsoft Excel ver. 2007). Statistical analysis Data was analysed using IBM SPSS 20.0 software (International Business Machines Corp, New York, USA). p \ 0.05 was considered significant. The following statistics were analysed:
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Fig. 1 Picture sets: Set 1
1. Descriptive statistics—means, standard deviations, medians and proportions were computed. 2. Both binary and continuous data analyses were carried out for numerical data. a. Binary data analyses: 1. CFSS-DS score was dichotomised into categorical variables to compare children with absence of clinical dental fear (i.e. CFSS-DS scores \38) and those with presence of clinical dental fear (CFSS-DS scores C38). 2. As there were children who presented with dmft = 0, the analyses also included an evaluation of those with and without caries (i.e. dmft = 0 and dmft [ 0). Chi-square test was carried out to see if there were any significant differences and associations in the distribution of these variables. b. Continuous data analyses: following evaluation of data for normality, the data were found to be non-parametric
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Table 1 Summary of demographics Parent (%)
Child
Age \30
15 (3.7)
5 years
143 (35.6 %)
30–39
226 (56.2)
6 years
188 (46.8 %)
40–49
152 (37.8)
7 years
71 (17.7 %)
50–59
9 (2.2)
Mean
5 years and 10 months
Male
111 (27.6)
Male
222 (55.2 %)
Female
291 (72.4)
Female
180 (44.8 %)
Gender
Race Chinese Malay
298 (74.1) 74 (18.4)
Indian
21 (5.2)
Others
9 (2.2)
Eur Arch Paediatr Dent Table 2 Child dental history
Table 3 Summary of overall preferences for dentist appearance
Previous visit to dentist
Number of visits
n (%)
No
0
72 (17.9)
Yes
1
86 (21.4)
2
71 (17.7)
3
55 (13.7)
4
36 (9.0)
[5
82 (20.4)
a
Dental procedures done in previous visits
Yes (%)
1st choice 2nd choice
190 (47.3)
Restorations
231 (57.5)
171 (42.5)
Extractions
72 (17.9)
330 (82.1)
Pulp treatment
49 (12.2)
353 (87.8)
in nature. Non-parametric tests (Mann–Whitney U, Kruskal–Wallis and Spearman’s correlation tests) were carried out. 3. McNemars test was used to investigate if there were any significant differences between paired categorical variables.
PPE
n = 143, 35.6 %
n = 133, 33.1 %
Paediatric coat
Paediatric coat n = 83, 20.6 %
White coat
Scrubs
n = 61, 15.2 %
n = 58, 14.4 %
Scrubs
Informal attire
n = 44, 10.9 %
n = 49, 12.2 %
5th choice
Formal attire
White coat
Last choice
n = 8, 2.0 % Informal attire
n = 40, 10.0 % Formal attire
3rd choice
n = 7, 1.7 %
n = 39, 9.7 %
Gender
Female
Male
n = 265, 65.9 %
n = 210, 52.2 %
Age
Young
Young
n = 271, 67.4 %
n = 351, 87.3 %
Race
Chinese (85.1 %) [ Malay (10.2 %) [ Indian (4.7 %)
Chinese (63.4 %) [ Malay (29.6 %) [ Indian (7.0 %)
a
Not all children received dental treatment at point of survey; some children received [1 category of treatment
PPE
n = 139, 34.6 %
4th choice 212 (52.7)
Child
Attire
No (%)
Scaling and polishing
Parent
Dentist’s age Results
Significantly more children were found to prefer a younger dentist (p \ 0.001, McNemars test).
Demographics Gender of dentist The demographics of the study population can be found in Table 1. Dental history The mean number of decayed, missing, filled primary teeth was 6.59 ± 4.7 (range 0–19). The majority of children (n = 357, 88.8 %) had dmft [ 0, while 45 (11.2 %) children had dmft = 0. Preferences for dentist’s appearance (Table 3) Dentist’s attire The attire most preferred by both parents and children was PPE, followed by the paediatric coat. However, this difference was not statistically significant (p [ 0.05, Chisquare test). Compared to children with dental experience, those visiting the dentist for the first time did not tend to choose the paediatric coat over PPE or other attires (p [ 0.05, Chi-square test).
Parents were found to prefer a female dentist to treat their children, while children preferred a male dentist. Children were also found to display a strong preference for a dentist with the same gender as their own (p \ 0.001, Chi-square test). Parent’s gender had no effect on their preference for dentist’s gender (p [ 0.05, Chi-square test). Race of dentist Participants tended to choose a dentist with the same ethnicity as themselves (p \ 0.001, Chi-square test). The racial preferences for parents and children were largely similar and reflective of the ethnic composition of Singapore’s resident population (Department of Statistics Singapore 2014). Similarity between parent’s and children’s choices The proportions of parents’ and children’s choices of dentist’s appearance were found to be largely dissimilar across all categories of attire, age, gender and race (p all \ 0.001, McNemars test).
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Eur Arch Paediatr Dent Fig. 2 Recruitment flowchart
Children’s fear survey schedule-dental subscale (CFSS-DS) The mean CFSS-DS score was 28.3 ± 11.4 (range 15–62). There were 277 (68.9 %) children who had scores \38 (no clinical dental fear), compared to 125 (31.1 %) children with CFSS-DS scores C38 (clinical dental fear present). The CFSS-DS scores were not normally distributed (p \ 0.001; Shapiro–Wilks test) (Figs. 2, 3). There was no significant difference in the CFSS-DS scores between children who had received dental treatment versus those without (p [ 0.05). The child’s CFSS-DS score did not influence their preference for the dentist’s attire, age, gender or ethnicity (p all [ 0.05). Regardless of whether they had dental fear, slightly more children preferred PPE attire to the paediatric coat, however, this difference was not statistically significant (p [ 0.05). A significant correlation between CFSS-DS score and the number of previous dental visits was found (p = 0.002, Spearman’s correlation), with children having higher number of dental visits tending to display higher dental fear scores. Furthermore, there was a significant difference in CFSS-DS scores of children who had extractions (p = 0.024; Chi-square test) compared to those who did not.
Discussion In Singapore, free dental treatment is provided in all local primary schools, and most children have their first dental
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Fig. 3 CFSS-DS chart
visit at age 7. Pre-school children who attend the dentist often only do so if they have cavities or are in pain. Based on this, the authors postulated that children included in the study would have limited exposure to dental treatment, and hence are less likely to have developed a stereotype image of the dentist. As dentists wear PPE at the School Dental Service, the acceptability of this attire was assessed in addition to other attires evaluated in similar studies (Mistry and Tahmassebi 2009; Kuscu et al. 2009). PPE attire was found to be the most preferred attire for both parents and children, followed by the paediatric coat, suggesting that both were suitable attires in a paediatric dental setting. Children with
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no dental experience did not tend to choose the paediatric coat over PPE or other attires, indicating a diminished role of dental attire in relation to its effect on first impressions and child dental anxiety. Additionally, it is likely that familiarisation, as well as increased parental awareness of infection control standards could have accounted for the slightly increased preferences for PPE attire in this study. In both the medical and dental setting, the informal attire has been consistently reported as the least favoured choice of attire by adults (Barrett and Booth 1994; Rehman et al. 2005; Mistry and Tahmassebi 2009). This finding was also in this population, illustrating universal adult preference for healthcare professionals to be dressed in accordance to general workplace standards. Adult participants in this study were found to strongly prefer a dentist with the same ethnicity as themselves. In general, adults tend not to report any preference with regards to the choice of ethnicity of their doctors (Kanzler and Gorsulowsky 2002). Of the studies which did, adults were more inclined to choose doctors of their own ethnicity mainly due to communication reasons, in which the ability to speak the same native language was cited as the main reason for their choice (Miller et al. 2011). As Singapore is a multi-racial country where citizens are largely bilingual, it is likely that parents felt more comfortable seeing a dentist who was able to communicate with them and the child in their mother tongue. As with other studies, children in this population were found to prefer dentists of the same gender as themselves (Mistry and Tahmassebi 2009). Female paediatric patients in particular have been observed to express a strong gender preference for their physician, and were more comfortable if being treated by a physician of the same gender. This is important in relation to a patient’s feelings of comfort, where the health provider’s ability to meet this preference could affect the doctor–patient relationship at the critical developmental moment (Turow and Sterling 2004). Contrastingly, parents independent of gender were found to prefer a female over a male dentist to treat their child, which could be reflective of adult perceptions that females related better to children or were gentler in the clinic (Shah and Ogden 2006). Although the mean caries rate of this population was high, majority of children had low dental fear levels, possibly attributed to their limited exposure to anxiety provoking dental procedures (e.g. pulp treatment and extractions) at the time of the survey. On the other hand, increased number of previous dental visits, as well as a history of having extractions corresponded to higher CFSS-DS scores. Of Rachman’s three pathways leading to fear, conditioning is largely responsible for the development of fear in children (Townend et al. 2000). It is logical that children requiring more frequent dental
visits have higher treatment needs and are therefore more susceptible to experiencing an unpleasant dental visit or treatment fatigue. Similarly, subjective experience of pain during traumatic or invasive treatment is likely to play a more significant role in the development of dental fear (Lee et al. 2008; Townend et al. 2000). Other factors, e.g. adequate pain control during treatment, behaviour management and the child’s own temperament are probably more important factors which influence treatment outcomes as opposed to the effect of caries experience per se. Compared to other studies in the literature, the subjects recruited in this study were younger (Mistry and Tahmassebi 2009; Kuscu et al. 2009). It has been found in surveys that children aged 5–11 are less able to comprehend and reliably answer questions pertaining to their health status (Rebok et al. 2001). For this reason, a parental proxy was employed to evaluate the child’s level of dental fear using the CFSS-DS. While the use of a parental proxy is an acceptable practice in child behaviour studies (Varni et al. 2007), and parents have been found to be able to accurately predict their child’s levels of fear (Milgrom et al. 1994; Lee et al. 2008), a known limitation of the parental proxy is that anxious parents may reflect their own anxiety in the scoring process (Gustafsson et al. 2010). Although the mean CFSS-DS scores in this study were found to be lower than reported in the literature, overestimation of CFSS-DS scores by anxious parents is still possible. Hence for future studies, pictorial methods for direct self-reporting in younger children such as the Dental Anxiety Scale for 5 year olds (DA5) (Humphris et al. 2002), the pictorial version of the Modified Child Dental Anxiety scale (Howard and Freeman 2006), or a moveable barometer to assist younger children in completing the CFSS-DS (Howard and Freeman 2006) can be explored. Additionally, it is also possible that some child participants may not have acquired an understanding of age and ethnic variations, and may have indicated their preference for their dentist based on the physical appearance of the subjects shown in the photographs (e.g. friendly appearance of model). To improve on this, future studies could consider employing the use of cartoon illustrations of characters (e.g. with differing skin tone colours and wearing traditional outfits) depicting the major ethnic groups instead of using photographs. Other factors, e.g. the child’s personality or previous experiences, may also play a crucial role in affecting the child’s level of dental fear. However, the questionnaire in this study was not designed to evaluate this. It may also be of value to evaluate longitudinally in future studies, the effect and pattern of dental fear in children with high caries rates who are subjected to multiple dental appointments.
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Conclusion Both parents and children preferred dentists who dressed in either PPE or paediatric coats, who were younger and of the same ethnicity as themselves. Parents preferred female dentists as their child’s dentist, whereas children preferred their dentist to be of the same gender as themselves. CFSSDS was significantly associated with increased number of previous dental visits and a history of extractions, but not with child’s dmft or preferences for attire, age, gender and ethnicity of the dentist. The results suggest that contrary to popular belief, dentists’ appearance per se may not play such a significant role in influencing a young child’s level of anxiety. Acknowledgments The authors wish to thank Dr Eu Oy Chu, the nurses and patients at the School Dental Service, Health Promotion Board for their kind assistance with the study.
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ORIGINAL SCIENTIFIC ARTICLE
Children’s and parents’ attitudes towards dentists’ appearance, child dental experience and their relationship with dental anxiety H. J. Tong • J. Khong • C. Ong • A. Ng Y. Lin • J. J. Ng • C. H. L. Hong
•
Received: 17 December 2013 / Accepted: 21 March 2014 European Academy of Paediatric Dentistry 2014
Abstract Aim To evaluate child and parental attitudes towards dentists’ appearance, subsequently related to a child’s dental experience and their association with child’s anxiety levels. Methods 402 parent–child pairs were surveyed using interviewer-administered questionnaires at the School Dental Service, Health Promotion Board, Singapore. Standardised pictures of models with different attires, ages, genders and ethnicities were shown to the parent–child pairs. Information on each child’s dental experience was obtained. Parental proxy was used to evaluate the children’s dental fear levels based on the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS). Results Personal protective equipment (PPE) was the attire of choice for both parents and children, followed by the paediatric coat. Formal and informal attire was least preferred by children and parents, respectively. Parents preferred female dentists to treat their child, whereas children preferred a dentist of the same gender (p \ 0.001). Parent’s and child’s preferences for the child’s dentist’s appearance were shown to be significantly different
H. J. Tong (&) J. Khong C. Ong A. Ng Y. Lin C. H. L. Hong Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, 11 Lower Kent Ridge Road, Singapore 119083, Republic of Singapore e-mail: [email protected] H. J. Tong School Dental Service Level 4, Health Promotion Board, 3 Second Hospital Avenue, Singapore 168937, Republic of Singapore J. J. Ng The Oral Care Centre, 10 Sinaran Drive, #10–17/#10–04, Singapore 307506, Republic of Singapore
(p \ 0.001). CFSS-DS scores were also significantly associated with the number of previous dental visits (p = 0.002) as well as a history of extractions (p = 0.02), but not with child’s demographics, dmft or preference for dentist’s appearance (p [ 0.05). Conclusion Regardless of child anxiety levels, the PPE followed by paediatric coats were preferred over other choices of dentists’ attire. Children tended to choose a dentist who was of a younger age, and of the same gender and ethnicity as themselves. Parents tended to choose younger, female dentists of the same ethnicity as themselves. Subjective experience of extractions, as well as multiple dental visits appeared to play a more significant role in the development of dental fear than dental caries experience per se. Keywords
Dentist attire Dental anxiety Dental fear
Background Childhood dental fear is common among children (Rantavuori et al. 2009). The estimated prevalence of childhood dental fear reported in the literature ranges from 4 to 43 % in different populations (ten Berge et al. 2002). Children are thought to be afraid of the dentist as a result of separation anxiety from their caregiver and the feeling of helplessness in a foreign environment, as well as their fear of bodily harm and corresponding perception of dental instruments as objects of pain, violence and destruction (Sharma and Sharma 1976). Differences in age, gender, personality, previous painful dental experiences, and increased general and parental dental anxiety can also account for fear in certain children (Klaassen et al. 2002). Dental fear is a major hindrance to the delivery of quality
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dental care and may become a problem for both dentists and patients. For a dentist, dental anxiety is an obstacle to good cooperation and a stress-free relationship between a patient and their dentist; whereas for the fearful patient, avoidance of dental treatment due to dental anxiety may lead to poorer oral health (Berggren and Linde 1984). Several scales that have been used to measure and assess dental fear in children, and they are broadly categorised into four groups: (1) Behaviour rating during dental visits (e.g. Frankl scale), (2) Physiological measures (e.g. pulse rate, basal skin response and muscle tension), (3) Projective techniques (e.g. children’s dental fear picture test, Modified Child Dental Anxiety Scale) and (4) Psychometric scales (Yamada et al. 2002). Of the many psychometric scales available, the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) is most frequently used for the determination of dental fear and anxiety (Cuthbert and Melamed 1982). CFSS-DS has been translated into several languages for use in different countries, and is favoured in research studies because of its ease of administration, along with good reliability and validity (ten Berge et al. 2002; Gustafsson et al. 2010), and is regarded as the ‘gold standard’ measure of the child dental anxiety inventory (Howard and Freeman 2006). A patient’s perception of a physician’s ability has been shown to be influenced by their appearance, which in turn can also affect the anxiety and comfort level of patients receiving treatment (Brosky et al. 2003). Children as young as 5 years of age have been found to be capable of forming judgments of their dentist based on his or her appearance, which in turn may influence their behaviour in the dental chair (Barrett and Booth 1994; Marino et al. 1991; Townend et al. 2000). One study evaluating the effect of dentists’ appearance found that adults generally preferred their dentists to dress traditionally (i.e. white coat) or in formal attire (Mistry and Tahmassebi 2009). However, the literature on children’s preference of attire for their dentist reports conflicting results, where some studies noted that children preferred their dentist to be in casual attire (Brosky et al. 2003; Mistry and Tahmassebi 2009), while others favoured their dentists in traditional attire (McCarthy et al. 1999; Kuscu et al. 2009). Age and gender can also affect patients’ perception of their dentist. While adults did not appear to display a significant preference with regards to the age and gender of their physicians (Kanzler and Gorsulowsky 2002; Keenum et al. 2003), children on the other hand have been found to display strong gender preference for their healthcare professional (Turow and Sterling 2004; Mistry and Tahmassebi 2009). The effect of ethnicity on patient’s perception of the appearance of their healthcare professional is also not well established. African-American patients were found to value their physician’s appearance more highly and were more
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trusting of well-dressed physicians as compared to Caucasian patients (Rehman et al. 2005). Likewise, Asian children were found to prefer physicians in white coats (Marino et al. 1991; Barrett and Booth 1994; Mistry and Tahmassebi 2009). This suggests that ethnic and cultural differences can influence both adults’ and children’s perception and hence personal preferences of their healthcare professional (Barrett and Booth 1994). Psychologists and sociologists stress the strong relationship between appearance and its effect on first impressions and interpersonal relationships. This information is important as it can help dentists better shape their practices to meet the preferences and needs of their patients. Multi-racial societies with diverse cultural and environmental influences such as Singapore may have varying perceptions of ethnicity, gender and attire as compared to western nations (Department of Statistics Singapore 2014). As such, it may be inaccurate to generalise findings of previous research for application into the local context. This study aimed to assess Singaporean children and parental attitudes towards dentists’ appearance with regards to their attire, age, gender and ethnicity. The secondary aims of the study were to explore: The association between child’s dental fear and their preferences for dentist’s appearance, and the relationship between child’s dental fear and number of treatment visits, treatment procedures, as well as decayed, missing and filled teeth in the primary dentition (dmft).
Materials and methods Ethics approval and participant recruitment Approval from the National University of Singapore Institution Review Board and the Health Promotion Board Medical Board was obtained prior to commencement of the study (NUS IRB Reference code 12-009; approval number NUS 1502). Potential participants were identified through the clinic list and approached while they were waiting for their appointment. Informed consent from the parents and child assent was obtained. Sample This was a cross-sectional observational study. The participants of the study consisted of children and their parents who attended the paediatric dental clinics at the School Dental Service, Health Promotion Board, Singapore. Recruitment was carried out from March to June 2012. The inclusion criteria were as follows: •
Adults and children who were able to understand and communicate in English or Mandarin language.
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• •
Children who were between 5 and 7 years of age (inclusive). Children who had a physical status of ASA 1 or 2 (American Society of Anesthesiologists 2014). The exclusion criteria were as follows:
• • •
Children who were cognitively disabled and unable to complete the survey independently. Children of ASA 3 and above. Children who were not accompanied by their parents.
Sample size As there were no similar studies carried out in Singapore, the sample size for this study was computed based on estimates. Aiming to detect a minimum difference of 1.123, and assuming a standard deviation of 8 on the CFSS-DS anxiety scale (range 0–75), with a of 0.05 and 80 % power, the minimum sample size needed for this study was 400 parent–child pairs.
Set 1: Evaluation of attire: photographs of a male and female model dressed in six different attires (formal, paediatric coat, scrubs, white coat, personal protective equipment, informal) were shown. Smiley faces were superimposed onto the faces (Fig. 1). Parents and children were asked to rank how they would prefer their dentist to be dressed, starting with the most preferred and the least preferred. Thereafter, they were then asked to rank the remainding four attires from most to least preferred. Set 2: Evaluation of age: photographs of paired male and female models of two distinct age groups (depicting young and senior) were shown. Participants were asked if they preferred a younger or older dentist. Set 3: Evaluation of gender: photographs of an individual male and female model were shown. Participants were asked if they preferred a male or female dentist. Set 4: Evaluation of ethnicity: photographs of paired male and female models of three different ethnicities (Chinese, Indian, and Malay), depicting the three main races in Singapore, were shown. Parents and children were asked to rank which ethnicity they would prefer their dentist to be, from most to least preferred.
Data collection Section 3: CFSS-DS Parents and children were surveyed separately using an interviewer-administered questionnaire. The parent’s questionnaire consisted of three sections, while the child’s questionnaire involved questions only from Sect. 2: Section 1: demographics, child’s medical and dental history • • •
Demographics—age, gender and ethnicity of parent and child, as well as any parental relationship to each child Child’s medical history Child’s dental history—first visit appointment (yes/no), dental treatment received (yes/no), and type of treatment received (scaling and polishing, fillings, extractions and pulp treatment) where appropriate. Information on each child’s number of previous dental visits, treatment received and caries status was verified using the electronic dental records system.
Section 2: questionnaire survey Four sets of photographs were shown to the participants. In all the photographs, facial expression, posture and hairstyle were kept as similar as possible. None of the individuals pictured in the photographs were involved in the survey or treatment process. The option for ‘‘no preference’’ was not available, thus ensuring that all participants had to make a decision among the photographs shown.
Parents were asked to determine the anxiety level of their child using the CFSS-DS and were asked to score a list of 15 questions in different domains contributing to dental anxiety based on a Likert scale ranging from 1 (not afraid) to 5 (very afraid) (Majstorovic et al. 2003). The scores were then summated to give the CFSS-DS score (range 15–75). For ease of comparison with existing studies (Gustafsson et al. 2010), a score of 38 was set as the cut-off for clinical dental fear, with a score of \38 denoting absence of clinical dental fear, and C38 indicating presence of clinical dental fear. Pre-testing of the questionnaire was conducted on 10 parent–child pairs to ensure the questions were fit for purpose, to test for ease of understanding, ambiguity, and to evaluate the workflow of the data collection process. Results obtained from the questionnaire testing were not included in the data analysis of the final study. Data was collected onto optical mark recognition (OMR) sheets, which were scanned using the Remark Office OMR software via a Kodak i2400 scanner, and converted into an Excel spreadsheet (Microsoft Excel ver. 2007). Statistical analysis Data was analysed using IBM SPSS 20.0 software (International Business Machines Corp, New York, USA). p \ 0.05 was considered significant. The following statistics were analysed:
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Fig. 1 Picture sets: Set 1
1. Descriptive statistics—means, standard deviations, medians and proportions were computed. 2. Both binary and continuous data analyses were carried out for numerical data. a. Binary data analyses: 1. CFSS-DS score was dichotomised into categorical variables to compare children with absence of clinical dental fear (i.e. CFSS-DS scores \38) and those with presence of clinical dental fear (CFSS-DS scores C38). 2. As there were children who presented with dmft = 0, the analyses also included an evaluation of those with and without caries (i.e. dmft = 0 and dmft [ 0). Chi-square test was carried out to see if there were any significant differences and associations in the distribution of these variables. b. Continuous data analyses: following evaluation of data for normality, the data were found to be non-parametric
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Table 1 Summary of demographics Parent (%)
Child
Age \30
15 (3.7)
5 years
143 (35.6 %)
30–39
226 (56.2)
6 years
188 (46.8 %)
40–49
152 (37.8)
7 years
71 (17.7 %)
50–59
9 (2.2)
Mean
5 years and 10 months
Male
111 (27.6)
Male
222 (55.2 %)
Female
291 (72.4)
Female
180 (44.8 %)
Gender
Race Chinese Malay
298 (74.1) 74 (18.4)
Indian
21 (5.2)
Others
9 (2.2)
Eur Arch Paediatr Dent Table 2 Child dental history
Table 3 Summary of overall preferences for dentist appearance
Previous visit to dentist
Number of visits
n (%)
No
0
72 (17.9)
Yes
1
86 (21.4)
2
71 (17.7)
3
55 (13.7)
4
36 (9.0)
[5
82 (20.4)
a
Dental procedures done in previous visits
Yes (%)
1st choice 2nd choice
190 (47.3)
Restorations
231 (57.5)
171 (42.5)
Extractions
72 (17.9)
330 (82.1)
Pulp treatment
49 (12.2)
353 (87.8)
in nature. Non-parametric tests (Mann–Whitney U, Kruskal–Wallis and Spearman’s correlation tests) were carried out. 3. McNemars test was used to investigate if there were any significant differences between paired categorical variables.
PPE
n = 143, 35.6 %
n = 133, 33.1 %
Paediatric coat
Paediatric coat n = 83, 20.6 %
White coat
Scrubs
n = 61, 15.2 %
n = 58, 14.4 %
Scrubs
Informal attire
n = 44, 10.9 %
n = 49, 12.2 %
5th choice
Formal attire
White coat
Last choice
n = 8, 2.0 % Informal attire
n = 40, 10.0 % Formal attire
3rd choice
n = 7, 1.7 %
n = 39, 9.7 %
Gender
Female
Male
n = 265, 65.9 %
n = 210, 52.2 %
Age
Young
Young
n = 271, 67.4 %
n = 351, 87.3 %
Race
Chinese (85.1 %) [ Malay (10.2 %) [ Indian (4.7 %)
Chinese (63.4 %) [ Malay (29.6 %) [ Indian (7.0 %)
a
Not all children received dental treatment at point of survey; some children received [1 category of treatment
PPE
n = 139, 34.6 %
4th choice 212 (52.7)
Child
Attire
No (%)
Scaling and polishing
Parent
Dentist’s age Results
Significantly more children were found to prefer a younger dentist (p \ 0.001, McNemars test).
Demographics Gender of dentist The demographics of the study population can be found in Table 1. Dental history The mean number of decayed, missing, filled primary teeth was 6.59 ± 4.7 (range 0–19). The majority of children (n = 357, 88.8 %) had dmft [ 0, while 45 (11.2 %) children had dmft = 0. Preferences for dentist’s appearance (Table 3) Dentist’s attire The attire most preferred by both parents and children was PPE, followed by the paediatric coat. However, this difference was not statistically significant (p [ 0.05, Chisquare test). Compared to children with dental experience, those visiting the dentist for the first time did not tend to choose the paediatric coat over PPE or other attires (p [ 0.05, Chi-square test).
Parents were found to prefer a female dentist to treat their children, while children preferred a male dentist. Children were also found to display a strong preference for a dentist with the same gender as their own (p \ 0.001, Chi-square test). Parent’s gender had no effect on their preference for dentist’s gender (p [ 0.05, Chi-square test). Race of dentist Participants tended to choose a dentist with the same ethnicity as themselves (p \ 0.001, Chi-square test). The racial preferences for parents and children were largely similar and reflective of the ethnic composition of Singapore’s resident population (Department of Statistics Singapore 2014). Similarity between parent’s and children’s choices The proportions of parents’ and children’s choices of dentist’s appearance were found to be largely dissimilar across all categories of attire, age, gender and race (p all \ 0.001, McNemars test).
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Eur Arch Paediatr Dent Fig. 2 Recruitment flowchart
Children’s fear survey schedule-dental subscale (CFSS-DS) The mean CFSS-DS score was 28.3 ± 11.4 (range 15–62). There were 277 (68.9 %) children who had scores \38 (no clinical dental fear), compared to 125 (31.1 %) children with CFSS-DS scores C38 (clinical dental fear present). The CFSS-DS scores were not normally distributed (p \ 0.001; Shapiro–Wilks test) (Figs. 2, 3). There was no significant difference in the CFSS-DS scores between children who had received dental treatment versus those without (p [ 0.05). The child’s CFSS-DS score did not influence their preference for the dentist’s attire, age, gender or ethnicity (p all [ 0.05). Regardless of whether they had dental fear, slightly more children preferred PPE attire to the paediatric coat, however, this difference was not statistically significant (p [ 0.05). A significant correlation between CFSS-DS score and the number of previous dental visits was found (p = 0.002, Spearman’s correlation), with children having higher number of dental visits tending to display higher dental fear scores. Furthermore, there was a significant difference in CFSS-DS scores of children who had extractions (p = 0.024; Chi-square test) compared to those who did not.
Discussion In Singapore, free dental treatment is provided in all local primary schools, and most children have their first dental
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Fig. 3 CFSS-DS chart
visit at age 7. Pre-school children who attend the dentist often only do so if they have cavities or are in pain. Based on this, the authors postulated that children included in the study would have limited exposure to dental treatment, and hence are less likely to have developed a stereotype image of the dentist. As dentists wear PPE at the School Dental Service, the acceptability of this attire was assessed in addition to other attires evaluated in similar studies (Mistry and Tahmassebi 2009; Kuscu et al. 2009). PPE attire was found to be the most preferred attire for both parents and children, followed by the paediatric coat, suggesting that both were suitable attires in a paediatric dental setting. Children with
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no dental experience did not tend to choose the paediatric coat over PPE or other attires, indicating a diminished role of dental attire in relation to its effect on first impressions and child dental anxiety. Additionally, it is likely that familiarisation, as well as increased parental awareness of infection control standards could have accounted for the slightly increased preferences for PPE attire in this study. In both the medical and dental setting, the informal attire has been consistently reported as the least favoured choice of attire by adults (Barrett and Booth 1994; Rehman et al. 2005; Mistry and Tahmassebi 2009). This finding was also in this population, illustrating universal adult preference for healthcare professionals to be dressed in accordance to general workplace standards. Adult participants in this study were found to strongly prefer a dentist with the same ethnicity as themselves. In general, adults tend not to report any preference with regards to the choice of ethnicity of their doctors (Kanzler and Gorsulowsky 2002). Of the studies which did, adults were more inclined to choose doctors of their own ethnicity mainly due to communication reasons, in which the ability to speak the same native language was cited as the main reason for their choice (Miller et al. 2011). As Singapore is a multi-racial country where citizens are largely bilingual, it is likely that parents felt more comfortable seeing a dentist who was able to communicate with them and the child in their mother tongue. As with other studies, children in this population were found to prefer dentists of the same gender as themselves (Mistry and Tahmassebi 2009). Female paediatric patients in particular have been observed to express a strong gender preference for their physician, and were more comfortable if being treated by a physician of the same gender. This is important in relation to a patient’s feelings of comfort, where the health provider’s ability to meet this preference could affect the doctor–patient relationship at the critical developmental moment (Turow and Sterling 2004). Contrastingly, parents independent of gender were found to prefer a female over a male dentist to treat their child, which could be reflective of adult perceptions that females related better to children or were gentler in the clinic (Shah and Ogden 2006). Although the mean caries rate of this population was high, majority of children had low dental fear levels, possibly attributed to their limited exposure to anxiety provoking dental procedures (e.g. pulp treatment and extractions) at the time of the survey. On the other hand, increased number of previous dental visits, as well as a history of having extractions corresponded to higher CFSS-DS scores. Of Rachman’s three pathways leading to fear, conditioning is largely responsible for the development of fear in children (Townend et al. 2000). It is logical that children requiring more frequent dental
visits have higher treatment needs and are therefore more susceptible to experiencing an unpleasant dental visit or treatment fatigue. Similarly, subjective experience of pain during traumatic or invasive treatment is likely to play a more significant role in the development of dental fear (Lee et al. 2008; Townend et al. 2000). Other factors, e.g. adequate pain control during treatment, behaviour management and the child’s own temperament are probably more important factors which influence treatment outcomes as opposed to the effect of caries experience per se. Compared to other studies in the literature, the subjects recruited in this study were younger (Mistry and Tahmassebi 2009; Kuscu et al. 2009). It has been found in surveys that children aged 5–11 are less able to comprehend and reliably answer questions pertaining to their health status (Rebok et al. 2001). For this reason, a parental proxy was employed to evaluate the child’s level of dental fear using the CFSS-DS. While the use of a parental proxy is an acceptable practice in child behaviour studies (Varni et al. 2007), and parents have been found to be able to accurately predict their child’s levels of fear (Milgrom et al. 1994; Lee et al. 2008), a known limitation of the parental proxy is that anxious parents may reflect their own anxiety in the scoring process (Gustafsson et al. 2010). Although the mean CFSS-DS scores in this study were found to be lower than reported in the literature, overestimation of CFSS-DS scores by anxious parents is still possible. Hence for future studies, pictorial methods for direct self-reporting in younger children such as the Dental Anxiety Scale for 5 year olds (DA5) (Humphris et al. 2002), the pictorial version of the Modified Child Dental Anxiety scale (Howard and Freeman 2006), or a moveable barometer to assist younger children in completing the CFSS-DS (Howard and Freeman 2006) can be explored. Additionally, it is also possible that some child participants may not have acquired an understanding of age and ethnic variations, and may have indicated their preference for their dentist based on the physical appearance of the subjects shown in the photographs (e.g. friendly appearance of model). To improve on this, future studies could consider employing the use of cartoon illustrations of characters (e.g. with differing skin tone colours and wearing traditional outfits) depicting the major ethnic groups instead of using photographs. Other factors, e.g. the child’s personality or previous experiences, may also play a crucial role in affecting the child’s level of dental fear. However, the questionnaire in this study was not designed to evaluate this. It may also be of value to evaluate longitudinally in future studies, the effect and pattern of dental fear in children with high caries rates who are subjected to multiple dental appointments.
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Conclusion Both parents and children preferred dentists who dressed in either PPE or paediatric coats, who were younger and of the same ethnicity as themselves. Parents preferred female dentists as their child’s dentist, whereas children preferred their dentist to be of the same gender as themselves. CFSSDS was significantly associated with increased number of previous dental visits and a history of extractions, but not with child’s dmft or preferences for attire, age, gender and ethnicity of the dentist. The results suggest that contrary to popular belief, dentists’ appearance per se may not play such a significant role in influencing a young child’s level of anxiety. Acknowledgments The authors wish to thank Dr Eu Oy Chu, the nurses and patients at the School Dental Service, Health Promotion Board for their kind assistance with the study.
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