Vol. 26 No. 01 Jan-Mar 2017

Muhammad Danial Khalid1 BDS MSc
Zohaib Khurshid2                    BDS, MRes, MFGDP
Muhammad Sohail Zafar3    BDS, MSc, MFGDP, PhD
Imran Farooq4                          BDS, MSc
Rabia Sannam Khan5             BDS, MSc
Arqam Najmi6                           BDS, MSc

Muhammad Danial Khalid¹ BDS, MSc
Zohaib Khurshid² BDS, MRes, MFGDP
Muhammad Sohail Zafar³ BDS, MSc, MFGDP, PhD
Imran Farooq⁴ BDS, MSc
Rabia Sannam Khan⁵ BDS, MSc
Arqam Najmi⁶ BDS, MSc

Rakia Sahaf¹ BDS, MPhil
Nadia Naseem² MBBS, PhD
Aman-ur-Rehman³ MBBS, FCPS
Rabia Anjum⁴ BDS, MPhil
Abdul Hanan Nagi⁵ MB PhD, FCPS, FCPP, FRC Path

Omair Majeed¹ BDS
Tabassum Ahsan Quadeer² BDS, FCPS
Maria Habib³ BDS
Maazia Jawaid⁴ BDS
Rafia Mujahid⁵ BDS

Rabia Ali¹ BDS
Farhan Raza Khan² BDS, MS, MCPS, FCPS

Bilal Abdul Qayum Mirza¹ BDS, MPhil
Fareed Ahmad² BDS, MCPS
Muhammad Nasir Saleem³ BDS, FCPS

Beenish Khalil

ABSTRACT:

A hospital based study was conducted to investigate the major causes of establishment of phobia established in the childhood

OBJECTIVE: The objective of this study was to investigate the dental phobia in adults acquired during childhood

METHODOLOGY: A questionnaire was completed and data was collected from 60 patients (age 16-40) who were afraid to have dental treatment due to some negative and traumatic experience during early childhood. The data was analyzed using SPSS 19.0 and Microsoft excel.

RESULTS: A total of 60 patients aged 16-40 were evaluated, of which 32 were male and 28 were female. The average anxiety level for male and female was the same and there was no significant gender difference. Majority (58%) developed phobia when they were treated at 5-6 years of age. Majority of respondents developed phobia at government hospital (53%). Endodontic treatment (43%) and exodontia (38%) were the most fear provoking procedures.

CONCLUSION:. Treatment at young age, treatment at government hospital and endodontic treatment were most frequent reasons for childhood phobia among study participants.

KEYWORDS: Dental Phobia, Dental treatment, Pediatric dentistry, behavior management.

HOW TO CITE: Khalil B. Dental Phobia Aquired in Childhood. J Pak Dent Assoc 2017; 26(1): 6-9

DOI: https://doi.org/10.25301/JPDA.261.6

Received: 22 December 2016, Accepted: 24 March 2017

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Bilal Abdul Qayum Mirza¹ BDS, MPhil
Fareed Ahmad² BDS, MCPS
Muhammad Nasir Saleem³ BDS, FCPS

Introduction

Dental caries is considered the single most common chronic childhood disease. The amount, consistency and frequency of sugar intake is considered a very important causative agent for caries.^1,2 Sticky foods remain on tooth surface for longer time and are harmful.

Carbohydrates in an adherent solid form are more cariogenic than their soluble state.3In addition to these, some socio-demographic and behavioral indicators responsible for an increased caries experience include; poor oral hygiene, inadequate tooth-brushing habits, increasing age, gender, frequency and timing of consumption of sugar-containing drinks, frequency of dental visits are also common factors4. In Pakistan WHO global data has shown an increase in DMFT of 12 years old children from 0.9 to 1.38.⁵

Early visit of the child to the dental clinic is considered the corner stone of the prevention programs. It is widely accepted that the timing of dental visits is important in preventing the onset and progression of dental caries.⁶ An early dental visit makes it possible for interceptive interventions
Fig. (1): Frequency of dental visits.

aimed at arresting the progression of caries lesions. A careful dental examination is not possible in very young children, but an inspection of the teeth and gingivae is often possible at one year of age, and has been advocated by a recent Nordic consensus conference.⁷

There is scarcity of data available which would highlight the dental caries experience and use of dental services among female students and for this reason this study was undertaken.

methodOLOGY

The sample of this analytical cross sectional study was female students ranging from playgroup to grade 10. A total of 5,538 female students often Garrison public schools from playgroup to grade 10 were included in the study. These schools are located in the Cantonment area of Lahore, Pakistan. The data gathered included demographic, DMFT score and frequency of dental visits. Prior to the study, the consent was sought from the parents’ of the students and the ethical approval for this study was given by IRC (institutional research committee) of Institute of Dentistry CMH Medical College. Six calibrated dentists examined the students in natural light. The students were seated on a chair and orally examined using mirror tweezer and probe. A DMFT proforma was filled according to WHO criteria for assessing dental caries⁸.

Inclusion Criteria

• All female students attending the schools from playgroup to grade 10.
• Only students’ whose parents provided consent were examined.

Exclusion Criteria

• Mentally handicapped children.

All the students examined were given oral hygiene instructions and demonstrated proper brushing technique.

The data were analyzed using SPSS v.24.

Statistical Analysis

Mean age and DMFT was calculated from the sample. The dental visits were grouped into four categories (0-6 months, 7-12 months, once in 2 years, Never). Chi test was used to analyse association between DMFT and no of dental visits. Statistical significance was set at 0.05 or below.

Results

The total number of students were 5,538 and the average age for the sample was 8.81 ± 2.88.Fig. (1) shows the frequency of dental visits. It was observed that a majority (84%) never visited the dentist. Only 6 % of the female students visited the dentist in the past 6 months.

Fig. (2) represents the frequency of students with caries experience. Fig. (3) shows the distribution of DMFT with age among the female students. Table 1 highlights mean values of study variables.

Discussion

Dental caries is a major health dilemma in underdeveloped countries and it influences 60-90% of school going children.⁹In Pakistan oral health has had low priority in the health activities, which has resulted in large

Fig. (2). Shows frequency of DMFT in students (n=3190).

Fig. (3). Shows the distribution of DMFT with age.

Table 1. Mean Values of study variables.

unfulfilled needs of the population and over 90% of all oral diseases remain untreated¹⁰. The main objective of this study was to find out the progression of dental caries and its association with dental visits. Our results suggest a strong relationship between number of visits and DMFT (p=0.000). The study also revealed that the mean DMFT score of 2.48 ± 3.09 for female students. This also highlights the severity showing 57.6% (3,190) of the students with DMFT score of 1 or above. Out of these two third of the students (63.35%) had up to a DMFT score of 4. Figures like these are alarmingly high for a sample with a mean age of 8.81 ± 2.88. These scores are attributed mainly due to decay component of DMFT, with missing and filled teeth having a negligible contribution. These figures are higher than urban mean DMFT score of 2.26.¹⁰Reasons might include students belonging to a lower socioeconomic status, high intake of sugary diet or fewer dental visits.¹¹Usually food available in majority of the schools’ cafeteria have high sugar content in confectionaries and fizzy drinks. Students are more than inclined to consume these due to lack of awareness or better taste.

The results suggest that all students with exception of a few have 2.48 teeth which are carious. These are extremely high figures. The level of untreated caries leads to pain, discomfort and drop in the quality of life. The students also develop low self-esteem issues in the society along with average school days missed due to dental problems.¹²

Instead of letting the caries progress, a timely treatment is required. When asked about the frequency of visit to the dentist, it was seen that 84% of the students never went to the dentist. The ones who went either got extraction done or had fillings which had recurrent caries. Some of the reasons for not getting teeth checked on time, could include cost of the treatment, fear of going to the dentist ortiming of the dentists’ appointment availability. And we recommend a follow-up study to ascertain the association of causes mentioned.

The high cost factor can be addressed by the government to start a fully funded/subsidized dental health care program for school going children which liaisons with the local hospital. Unfortunately no such initiative has been taken by the government.

The fear is also an important factor which refrains the children to go to the dentist. This can be dealt with by periodically educating the students and discussing their fears. Parents should also be educated in this regard that they shouldn’t put innate fear of needles in child’s mind or put the fear of needles if the child disobeys the parent. This causes the child to be petrified of going to the dentist and hence doesn’t get treatment in time.

This study points the young female students have very high caries level and on top of that timely dentists’ visits are not attained which affects their quality of life and eventually their studies due to sickness.¹²

Recommendations

• The government should sponsor a dental health care plan where students can get treatment at a subsidized rate; if not fully funded; at the school premises or liaison with the nearest tertiary care hospital.

• The students along with their parents should be encouraged to get their teeth examined every six months.

• The parents should be educated about dental health issues and dental visits so they can get their child’s teeth treated accordingly.

Conclusion

The female students of Garrison public school were found to have a high caries experience. The use of dental services was poor.

footnotes

1 Associate Professor, Department Community & Preventive Dentistry, Institute of Dentistry, CMH Lahore Medical College. Pakistan.

2 Assistant Professor, Department of Oral Surgery, Institute of Dentistry, CMH Lahore Medical College. Pakistan.

3 Associate Professor, Department of Operative Dentistry, Institute of Dentistry, CMH Lahore Medical College. Pakistan.

Corresponding author: “Dr. Bilal Abdul Qayum Mirza” < bilal_abdul_qayum@hotmail.com >

References

1. Lingstrom P, Van Houte J, Kashket S. Food starches and dental caries. Crit Rev Oral Biol Med 2000; 11: 366-80.

2. Saravanan S, Madivanan I, Subashini B, Felix JW. Prevalence pattern of dental caries in the primary dentition among school children. Ind J Dent Res 2005; 16: 140.

3. Decker RT, Loveren CV. Sugar and dental caries. Am J Clin Nutr 2003; 78: 881-92.

4. Declerck D, Leroy R, Martens L, Lesaffre E, Garcia-Zattera MJ, Broucke VS, Debyser M, Hoppenbrouwers K: Factors associated with prevalence and severity of caries experience in preschool children. Community Dent Oral Epidemiol. 2008, 36: 168-78.

5. Bratthall D. Estimation of global DMFT for 12-yearolds in 2004. Int Dent J. 200; 55: 370-72.

6. American academy of pediatric dentistry. Reference. Manual 2006-07. Pediatric dent 2007;28:17-19.

7. Hagoson a, falk m, johansson s. Consensus conference on caries in the primary dentition and its clinical management. Stockholm: gothia, 2002:86.

8. World health organization (who). Oral health surveys: basic methods. 5th edition. Geneva, Switzerland: who. 2013.

9. AsgharA, Shama A, Seema S. Caries prevalence among school children age 6-14 years in Gadap Town Karachi in relation to the awareness of their parents toward oral health. Pak oral dent j 2013;33: 354-58.

10. Oral health in Pakistan: A situation analysis .Ministry of health/who publication ; Govt of Pakistan 2004.

11. Hawa S Mbawalla, Joyce R Masalu, and Anne N Åstrøm. Socio-demographic and behavioural correlates of oral hygiene status and oral health related quality of life, the Limpopo – Arusha school health project (LASH): A cross-sectional study. BMC Pediatr. 2010; 10: 87.

12. Jackson S.L., William F.V.Jr, Jonathan B.K.,Bhavna T.P, Jessica Y. L,.Impact of Poor Oral Health on Children’s School Attendance and Performance. Am J Public Health. 2011; 101: 1900–6.

Beenish Khalil BDS

INTRODUCTION

A behavior that leads to complete avoidance of a particular situation due to continuous fear of that situation is called as phobia. Fear is manifested in the form of anxiety which is provoked when the person is exposed to a particular stressful situation or stimulus. Over a period of time the anxiety converts into the panic attacks resulting in the establishment of restlessness and distress and disturbing the routine life of that person. A phobic will spend a lot of time thinking about fearful situations. Dental phobia is mainly identical to fear, only difference is its much stronger. The panic attacks can be provoked even by reminding the particular situation resulting in the avoidance of treatment. This painful response is mainly the reaction of some traumatic experience in the past either due to mishandling by dentist or dental auxillary. These incidents have a strong impact on the memory if they are caused in early childhood.

What ever be the type of fear and reason of the fear the dentist is considered as a culprit behind all these faults resulting in the development of fear and phobia.¹ Exogenous and endogenous anxieties are another types of fear classified in some other systems². University of Washington Categorized Dental Fear into four main categories i-e fear of specific stimuli and distrust of Dentist which are usually the result of past bad experience are categorized as exogenous while the generalized anxiety and fear of a medical emergency can be groups as endogenous³ most of the dental phobias are caused due to bad handling of the doctor⁴. This includes some painful procedure performed in dental clinic as well as some sort of psychological setback such as being humiliated or disgraced by a doctor or auxiliary. Careless dental professional is considered to be another big reason. The major psychological impact is not the pain itself rather the cold behavior of the dentist is the main disturbing thing resulting in establishment of fear of loss of control². Another reason of dental anxiety or phobia is established through listening to the stories of other people if a parent is scared and anxious about dental treatments or dental settings including the dentist, children even in the absence of any directly faced bad or painful experience will learn to be afraid as well⁵. Post-Traumatic Stress is another big contributing factor. Post traumatic stress disorder is strongly related to past experience that is horrific. it has been revealed that previous negative treatment and experiences have strong influence on the child psychology resulting in the averting behavior and fear towards the treatment it is directly linked to the genesis of fear in children⁶. On the other hand, fear can also be acquired through the negative modelling by the siblings and parents as a matter of fact⁷.

Although the national literature is replete with reports about frequency and various associated with dental anxiety, there are very few that focus a bad experience in childhood as a reason for adult dental phobia. It was therefore, the objective of the present study to investigate the specific causes of dental phobia acquired during childhood but manifested in adult age.

METHODOLOGY

A cross sectional study was conducted in Islamic International Dental Hospital and 2 established private clinics of Islamabad. The consent from the patients were obtained after proper explanation of the study from individuals who were willing to participate. Patients suffering from dental phobia belonging to either gender and age between 16-40 were included. A open ended format questionnaire was designed and self distributed to the patients. The questionnaire was composed of 12 questions. Data was collected from 60 patients using convenience sampling based upon the number of the patients available in the available period of time.. The data was analyzed using SPSS version 19.0 software for MS Windows.

RESULT

A total of 60 patients aged 16-40 were evaluated, of which 32 were male and 28 were female. The average anxiety level for male and female was the same and there was no significant gender difference. 16% of the total patients were at the age of 7-8 years when they have undergone through the treatment that resulted in the development of fear and phobia. 58 % were in the age group of 5-6 years while 25% were 4 years of age.

Majority of respondents developed phobia at government hospital (53%) followed by private hospital (31%) and private clinics (15%). (Fig no. 1) Investigating the behavior of Dental practitioner, 85% of the patients were of the view that they were not able to follow the dentist’s instructions and were not briefed about the nature of treatment prior to its commencement. Similarly, 45% reported that the dentist behaved rudely, and in an un-cooperative (26%) manner (fig no 2). Majority (78%) were not satisfied with environment of the dental setting.

Dental anxiety appeared to vary by type of treatment, with restorative / endodontic and exodontic patients reporting higher levels of anxiety, 43% and 38% respectively followed by patients receiving periodontal (11%) and prophylactic treatment (6%) (fig. no 3). Whereas, 88% patients reported to experience pain intra-operatively while 63% reported post-operative pain as well.

According to study participants’ self-assessment of the anxiety levels, 11% considered themselves as cooperate while 30% were of the view that they were highly irritable and the rest 58% regarded themselves as intensely anxious.

Psychological responses to dental phobia appeared as an amalgamation of worry regarding the white coat of the doctor (11%), about 16% were upset with the sound of the drill, the fear of pain and discomfort that might be caused during the treatment was the cause of panic in 33% of the patients while the feeling of helplessness and insecurity accounted for 18%. The atmosphere of the clinic was the source of disturbance for almost 20% of the patients.

Fig. (1).

Fig. (2).

Fig. (3).

DISCUSSION

A perturb emotion strongly provoked by danger or pain is known as fear, irrespective of the fact that it is real or fabricated a fear that is incontrollable and irrational turns into a phobia. It is creditable to note that most of the time fears are boosted by irrational imagination⁸ fear conditioning is referred to the type of the fear that is acquired through specific learning. Either through personal experience of a traumatic or painful event⁹. The root cause of phobia and anxiety, specifically in the dental setting, has a intricate and multi-factorial physiological and psychological etiology¹⁰. Several factors contribute to the etiology of dental phobia an innate predisposition, conditioning differences in psychological behavior and fear associated with the direct stimulation or non-associative perspective are considered to be the four universal causes⁹. The most important and common cause of dental phobia is the negative traumatic and painful event in the childhood mostly early childhood¹⁰. An offensive, discourteous and ungracious behavior of the dental professional act as the initial stimulus which precipitate the patterns of fear and anxiety11. The anxiety of the caretaker specially the mother directly influences the child¹². The children look towards their parents and consider them role as a model for themselves¹³. Along with the behavior the physical appearance, facial expression, tone and pitch of voice are also considered as triggers for dental fear. So both verbal and nonverbal factors are important for consideration in order to avoid the establishment of phobia in the early childhood¹⁴. Mean while the alterations in the dental care delivery system and the behavior of the dental professional may not be ample to deal with the phobias and fears if the behavior of the parents and the children are not checked they need to be focused at the first pace15. Another big causative impact factor is the environment of the clinic or the setting16. Fortunately, most of the professionals are competent in managing fearful and phobic patients and have developed number of ways that helps in reducing the pain and assuage fear in the dental setting¹⁷. Relaxation strategies are proved to be very successful in relieving the anxiety resulting in the slowing down of the physical reactions of the body in response to anxiety and fear. Deep breathing exercises like simple breathing followed by paced inhalation and exhalation proved to be very useful. likely Progressive muscle relaxation which involves sequentially tensing and relaxation of particular group of muscle may also be helpful¹⁸. If time constraint is not a problem than using relaxational strategies along slow and gradual exposure to the object one is afraid of is known as systemic desensitization and is considered as very effective method¹⁹. The tell show and do technique in which the child is slowly been exposed to the thing or aspect he is worried of until he become able to overcome that fear as an example if a child is afraid of the injections the dentist must start by slowly explaining the parts of injections until he become able to touch that syringe and completely understands its purpose with little to no anxiety¹⁸. Distraction techniques are also considered to be supportive and aiding. This type of strategy usually involve using a toy in the dental chair, asking the child to remember a recent happy experience, allocating the

Fig. (04).

child some task like counting the tiles in the ceiling while sitting in the office of the dentist during the treatment it will help in the deflection of the attention²⁰. The best distraction technique is the music according to recent studies²¹. Awarding little compliments in response to positive behavior is very effective method²².

CONCLUSION

Within the limitations of this study treatment at young age, treatment at government hospital and endodontic treatment were most frequent reasons for childhood phobia among study participants.

QUESTIONNAIRE

1. What was your age when you first visited the dentist office?
2. Where the treatment was done?
3. Do you have any idea prior to the treatment/were you mentally prepared for the treatment?
4. Were you satisfied with the atmosphere and environment of the clinic?
5. The attitude of the doctor and the staff was?
6. What was the treatment?
7. Was the treatment painful?
8. Was there any post operative pain?
9. You rate your attitude at the time of treatment as?
10. Were your parents present at chair side?
11. what was the attitude of your parents?
12. What fears you most while walking to a dentist office?

FOOTNOTES

Islamic International Dental College Pakistan
Corresponding author: < beenishkhalil@hotmail.com >

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