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Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 17-22

Influence of Mothers’ Dental Anxiety and Perception of Child’s OHRQoL Towards Utilization of Dental Services − A Questionnaire Study

1 Department of Pedodontics and Preventive Dentistry, Vinayaka Mission Sankarachariyar Dental College, Salem, Tamil Nadu, India
2 Department of Public Health Dentistry, JKK Nattraja Dental College, Namakkal, Tamil Nadu, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Kruthika Murali
Department of Pedodontics and Preventive Dentistry, Vinayaka Mission Sankarachariyar Dental College, Ariyanoor, Salem 636308, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_190_16

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Introduction: Dental caries is one of the most common oral health problems in childhood. As a child depends entirely on the parents, its dental visit could be influenced by various psychosocial factors such as parental perceptions of the child’s oral health and maternal anxiety. Aim: To assess the influence of children’s clinical condition, mothers’ dental anxiety and their use of dental services, maternal perception of child’s oral health-related quality of life (OHRQoL) on the child’s utilization of dental services. Materials and Methods: A cross-sectional survey was conducted among 600 mothers of children between 2 and 5 years of age. The questionnaire included the background characteristics, mothers and child’s dental visit, mothers’ dental anxiety using Corah’s Dental Anxiety Scale and maternal perceptions of the child’s OHRQoL using Early Childhood Oral Health Impact Scale. Clinical examination for assessing the dental caries among the children was performed. The data were analyzed using the Statistical Package for the Social Sciences version 17.1 software. Results: Using the final model of Poisson regression analysis with robust variance and forward stepwise procedure, it was found that the age of mother, the age of child, the income of the family, poor OHRQoL, the presence of caries and pain in child significantly influenced the visit of the child to dentist (P ≤ 0.05). No statistically significant association was found between the anxiety of mother and the child’s visit. Conclusion: Lack of maternal knowledge, low socio-economic reasons and maternal perception of child’s oral health could be the important reasons for a child’s less number of dental visits.

Keywords: Corah’s Dental Anxiety Scale, ECOHIS, mothers’, dental anxiety, OHRQoL

How to cite this article:
Murali K, Shanmugam S. Influence of Mothers’ Dental Anxiety and Perception of Child’s OHRQoL Towards Utilization of Dental Services − A Questionnaire Study. J Indian Assoc Public Health Dent 2017;15:17-22

How to cite this URL:
Murali K, Shanmugam S. Influence of Mothers’ Dental Anxiety and Perception of Child’s OHRQoL Towards Utilization of Dental Services − A Questionnaire Study. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2024 Feb 27];15:17-22. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2017/15/1/17/201938

  Introduction Top

Dental caries remains as a pre-eminent oral disease of childhood in-spite of its decreasing prevalence. Therefore, it is considered the primary marker of children’s oral health, whereas visits to a dentist are considered a marker of care.[1] It is recommended that a child’s first visit to a dentist happens by the age of 1 year.[2] This early visit gives a dentist a chance to improve the child’s oral hygiene, to correct improper dietary habits, and to improve parents’ knowledge.[3]

Oral health problems have been increasingly recognized as important factors causing a negative impact on daily performance and quality of life because it influences how people grow, enjoy life, speak, chew, taste food and socialize.[4] Additionally, poor oral health of children may compromise the family welfare, because the parents feel guilty for their children’s problems and have work absence and expenditures associated with dental treatment.[5]

The assessment of quality of life has become an integral part of evaluating health programs. In recent years, several instruments used to improve and validate oral health-related quality of life (OHRQoL) in children and adolescents have emerged.[6],[7],[8],[9],[10] The Early Childhood Oral Health Impact Scale (ECOHIS) was developed and validated in English in the United States to assess the impact of oral health problems and related treatment on the quality of life of preschool children (aged 3–5 years) and their families.[11] The ECOHIS has already been tested and validated among children in the United States, Canada, China and Iran.[11],[12],[13],[14]

Parental characteristics such as low maternal schooling level, family attendance patterns and presence of a health care system are frequently cited as barriers to dental care visits of children.[15],[16] Thus, parental characteristics, attitudes and perceptions may not only influence the parents own use of dental services but also their children’s use of dental services, because children depend on their parents for visits to a dentist.[3]

Despite the association of psychosocial factors with the use of dental care services in adults and older children, the influence of psychosocial factors, such as the parental perceptions of the child oral health[16] and maternal dental anxiety, on the use of dental services in preschool children[17] is unclear. Hence, the aim of the study is to assess the influence of the child’s oral health status, mothers’ dental anxiety and their use of dental services, maternal perception of child’s OHRQoL on the child’s utilization of dental services.

  Materials and Methods Top

The study was a cross-sectional survey with a clinical examination. Six hundred mothers of children between the age ranging from 2 to 5 years in the Thiruchengode Taluk, Tamil Nadu, India were invited to participate in the cross-sectional survey. The study consisted of questionnaire interview for the mothers and clinical examination for their children. It was conducted in 16 pre-schools (Palvadi) in and around Thiruchengode for a period of 4 months, and the sampling method followed was cluster random sampling. All the parents participated in this study signed an informed consent form. The study received approval from the ethics committee of the Vinayaka Missions University, Salem, Tamil Nadu, India.

The study consisted of a translation phase including two small pilot studies to assess the content validity of the instrument and a follow-up study to assess its test–retest reliability. Within a period of 4 weeks after the first interview, 15% of the participants were randomly selected by lots and agreed to repeat the ECOHIS and Dental Anxiety Scale (DAS) questionnaire. The reliability of the questionnaire has been checked by test–retest method, and the Cronbach’s alpha value for the same is 0.89. The repeated interview was performed individually with each parent/ guardian, and the interviewer was unaware of the results of the first interview.

To participate in the study, the children had to fulfil the following criteria: the subjects must be accompanied by a tamil speaking mother. Children with serious underlying medical conditions, long term use of medication and physical or learning disabilities were excluded from the study. Mothers of children, who met these inclusion criteria were interviewed. All the mothers agreed to participate in the study. The interviews were performed individually by a trained interviewer. Monthly family income and educational level of mother were classified based on modified Kuppusamy Scale.[18]

Mothers were asked about their use of dental services and whether their children had ever had a dental appointment. Maternal dental attendance pattern was classified as non-regular, if she answered that she [1] never goes to dentist or [2] goes to the dentist, when she feels pain or has a problem; and regular if she answered that she [3] goes to the dentist whether she has a problem or not or [4] goes to the dentist regularly.[19]

To assess maternal perceptions of their children’s OHRQoL, ECOHIS questionnaire was translated into vernacular language (Tamil) by a language specialist.

The ECOHIS consists of 13 questions divided into two main parts: child impact section (part one) and family impact section (part two). The child impact section comprises of four subscales: child symptom, child function, child psychology and child self-image/social interaction. The family impact section contains two subscales: parental distress and family function. The questionnaire is scored using a simple five-point Likert scale with responses ranging from ‘never’ to ‘very often’ (equivalent to a score of 0 and 4, respectively). A total score ranging from 0 to 52 is calculated as a simple sum of the responses with higher scores denoting a greater oral health impact and/or poorer OHRQoL.[11] ECOHIS scores were dichotomized using the median values as a cut-off point.[20]

To assess maternal dental anxiety, the Tamil version of the Corah’s DAS was used.[21] Mothers’ dental anxiety was categorized and classified as low (DAS score of 11 or less) or high (DAS score of more than 11).

On the basis of recommended World Health Organization[22] criteria for the visual assessment of dental caries, children underwent a clinical oral examination checked by a trained examiner. Caries experience was recorded using the DMFT index.

Statistical analysis

Using the Statistical Package for the Social Sciences version 17.1 software, Poisson regression analysis with robust variance and forward stepwise procedure was used to correlate the dependent and the independent variables. The P value was fixed at 5%.

  Results Top

A total of 600 child-mother dyad was included in the study.

The demographic variables, family characteristics, socio-economic variables, clinical characteristics, maternal dental anxiety and mothers perception of child oral health are presented in [Table 1]. About 59.3% of the mothers have visited the dentist before and 59.3% of the children have never visited the dentist. About 61.3% of the mothers were found to have high dental anxiety and 38.7% of children had previous experience of dental pain. Among the study group 44.7% of them had ECOHIS score ≥3.
Table 1: Demographic variables and socio-economic variables, clinical characteristic and maternal dental anxiety and perception of child oral health

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In the unadjusted model, the age of the mother, child age, income of the family, dental caries, child pain and ECOHIS were found to be significantly associated with the child’s use of dental service with P value ≤0.05. Further, these factors which was found to be associated with the child’s use of dental service was subjected to adjusted regression model, in which all the above mentioned factors were again found to be statistically significant with P value ≤0.05 [Table 2].
Table 2: Association between various predictor variables towards child’s usage of dental service

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Children, who had experienced decay and pain, and children of those mothers, who perceived their child’s quality of life was poor visited a dentist with higher frequency. Clinically significant factors such as mothers dental visit and mother dental anxiety do not show statistically significant association with child’s use of dental service [Table 2].

  Discussion Top

The present study assessed the influence between different variables and child dental visit pattern among 2–5-year children. This study consists of dental attendance pattern of child and its association with maternal dental anxiety and their perception about child’s oral health (ECOHIS).

Children’s self-concept and health cognition are age dependent and result from continuous cognitive, emotional, social and language development.[12] Up to the age of 5, children have difficulty in understanding basic health concepts, are incapable of adequately expressing themselves and tend to give exaggerated responses.[23] Children younger than 6 years do not have perception of health or disease;[24] thus, the burden of responsibility for general and oral health in very young children lies on their parents.[25] Hence, the questionnaire was filled out by parental proxy.

This study questionnaire was validated in the vernacular language (Tamil) as it is imperative to evaluate the different language versions of this instrument to assure that each version exhibits psychometric properties similar to the original version and guarantee its effective utilization in cross-cultural comparisons.[13] Interview method was used in the study, because it is helpful in obtaining higher response rate and to overcome the bias of self-reported questionnaire that may occur with patients with compromised language and visual communication skills.[26]

It was found in the present study that only a small percentage (40.7%) of the preschool children have visited a dentist, which was similar to the study performed by Medina-Solís et al.[26] (40%). Whereas the studies conducted by Goettems et al.[3] (20.7%) and Kramer et al.[27] (13.3%) showed much lesser percentage of dental attendance. The reason could be alarming lack of awareness about the importance of child oral health among mothers.

The weight of background characteristics and socio-economic conditions was also appraised. In the present study, income of the family has got a significance in child’s dental attendance pattern. It is known that children from low-income families tend to have the greatest needs and lowest use of dental services.[1] According to Armfield et al.,[28] people from lower socio-economic status are generally more fearful of dental treatment which is contradicting with the present study, where it was found that the low socio-economic group had more previous dental visits than the high socio-economic group Though they were no significant association found between the maternal schooling level and child’s dental visit, it is considered to be a determinant factor of a child visiting a dentist because education affects a person’s ability to understand, communicate and find appropriate health services.

Maternal attendance in the present study is 59.3%. Parents or guardians are put up with the duty of introducing pre-school children to the dentist. The results of this study showed the maternal turnout sample is a forecaster of children‘s use of dental services, because in the present study, the mothers who had visited the dental office had taken their children for dental visit. This was similar to study conducted by Grembowski et al.[29] and Isong et al.,[30] where they had found that parental oral health seeking behaviours for themselves may have an important effect on oral health seeking behaviours on behalf of their children.

The dental services utilization by parents for their children and adolescents is frequently determined by the presence of pain. In the present sample also, pain (65.6%) did influence parent’s taking their children to the dentist significantly compared to that of the study conducted by Goettems et al.[3] (30.9%). It was also found that presence of dental caries (91.8%) had significantly influenced their mothers for their child’s dental visit compared to that of the study conducted by Goettems et al.[3] (23.2%).

In the present study, it was found that mothers with high dental anxiety had taken their children to dentist slightly more than low dental anxiety mothers’, but the difference was not statistically significant, whereas the study conducted by Kinirons and McCabe[31] and Thomas and Startup[32] showed a significant difference between the low and high anxiety mothers with their child dental visit pattern.In the present study, mothers who perceived their child’s OHRQoL to be poor had taken their children to the dentist more than the mothers who perceived their child’s OHRQoL to be good. Mothers who consider that dental disease affects the OHRQoL of children negatively would, as a consequence, bring the child to the dentist. These findings are in accordance with those of Filstrup et al.,[33] who suggest that, until decay interferes with the child’s life, the parent/guardian may be unaware that a dental problem even exists. Maternal perception of their child’s OHRQoL was associated with utilization of dental services, confirming the fact that greater oral health need (perceived or normative) is an important predictor of use of dental health services in preschool children.[34]


The child’s own fear related to dental care was not assessed in this study, and this factor could also be important factor for dental visits. More studies with higher sample size and robust sampling model are needed to generalize this result.


India being the second populous country in the world, it has unique health problems, for which solutions are way beyond the health services available. Therefore, emphasis should be on preventive and promotive care. The assessment of OHRQoL of a community is required to formulate a patient centric and culturally acceptable oral health policy.[35] Dental education also needs to be refocused to incorporate OHRQoL in the curriculum.

  Conclusion Top

Lack of maternal knowledge, low socio-economic reasons and maternal perception of child’s oral health could be important reasons for child’s low dental visit.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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