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. Author manuscript; available in PMC: 2016 Jun 1.
Published in final edited form as: Eur Arch Paediatr Dent. 2014 Dec 17;16(3):283–290. doi: 10.1007/s40368-014-0161-9

Parent-Reported Distress in Children Under 3-years Old During Preventive Medical and Dental Care

Travis M Nelson 1, Colleen E Huebner 2, Amy Kim 3, JoAnna M Scott 4, Jacqueline E Pickrell 5
PMCID: PMC4470890  NIHMSID: NIHMS649971  PMID: 25514877

Abstract

Purpose

This study examined factors related to young children’s distress during preventive oral health visits. Additionally, associations between parent-reported child behavior during the dental visit and during prior medical visits were tested.

Methods

One hundred twenty two children under 3 years of age enrolled in a government insurance program for low-income children were seen for examination, prophylaxis, and fluoride application at a university-based dental clinic. Child distress was rated by parents on a numerical rating scale.

Results

The average age of children enrolled was 23.5 ± 7.3 months. The majority (55.7%) were judged to have little or no distress pre-examination. Mild or no distress during the examination was reported for 42.6% of the children and severe distress was reported for 39.4%. Intensity of distress during the examination was not associated with the child’s age, gender, dental health, or prior experience with dental care. Distress was also unrelated to the caregiver’s education level or own dental health. Intensity of distress was associated with the child’s pre-dental examination distress and distress during prior medical examinations and injections.

Conclusions

Dental professionals can better anticipate child distress by assessing children before examination and inquiring about previous medical experiences. Strategies to prepare parents and alleviate distress may help children cope with the preventive dental visit.

Keywords: stress, coping, infant, preventive dentistry

Introduction

Early preventive dental visits (PDV) are fundamental to the promotion of oral health in young children. Recognizing this, the American Academy of Pediatric Dentistry, the American Dental Association, the Canadian Dental Association, the European Academy of Pediatric Dentistry, and the American Academy of Pediatrics recommend that children have an oral health assessment by the first birthday. (AAPD 2012; CDA 2005; EAPD 2008; Hale 2003) As a result, more young children are now receiving dental care than in the past.(Garg et al. 2013) Early initiation of care provides an opportunity to perform risk assessment, screen for untreated dental disease, provide oral health counseling, and deliver preventive care such as fluoride varnish treatments.

Early preventive dental visits by young children enrolled in government insurance programs for low-income children are associated with greater use of preventive services in the future and with lower dental-related costs.(Savage et al. 2004; Sen et al. 2013) These findings extend over the life course, reducing overall disease experience into adulthood.(Bhaskar et al. 2014) However, receipt of recommended preventive visits is still generally low for US children, and not all children attend PDV at equal rates.(Landers et al. 2013; Yu et al. 2002) Disparities in dental visit attendance have been associated with large family size, young parent age, low educational levels, low income, difficulty finding a provider who accepts government insurance, transportation challenges, high parent dental anxiety, and poor perceived child oral health.(Alio and Salihu 2005; Committee on Oral Health Access to Services 2011; Goettems et al. 2012; Kataoka-Yahiro and Munet-Vilaro 2002; Kelly et al. 2005; Mofidi et al. 2002; Phillips et al. 2000; Piovesan et al. 2011; Smith and Lewis 2005; Watson et al. 2001)

Developing a habit of preventive care from a young age is particularly important for low-income children who are more likely to develop tooth decay and have, on average, more than twice the number of decayed teeth as do non-poor children.(Dye et al. 2007; Kaste et al. 1999; US DHHS 2000; Vargas et al. 1998) Children of lower socioeconomic groups are considered to be at higher risk for disease; therefore they should be given priority for preventive dental care before age 3.(Beil et al. 2013) Despite these recommendations, in the years 2005 – 2008, the proportion of all U.S. children reported to receive any preventive oral health care in the prior 12 months was only 21% and did not vary appreciably by family income. (Huebner et al. 2013) A recent cross sectional study indicated that children in a Canadian sample from low-income families were least likely to have visited the dentist by age one and most likely to have cavities.(Darmawikarta et al. 2014)

Unlike dental care for adults, care for young children necessitates a triadic relationship among the patient, parent, and clinician. Emotional aspects of the dental experience, for the child and the parent, influence a parent’s decision to return for subsequent dental visits. For example, parents of preschool-age children in need of restorative treatment describe their child’s crying and upsetting behaviors during prior dental visits as a primary reason they avoided seeking recommended care.(Bitar King et al. 2011; Song and Pickrell 2010) Conversely, a positive experience can influence the family to return for additional preventive treatments, increase confidence in oral health home care maintenance, and promote positive outcomes at return visits.(Zhou et al. 2013) Concerns about children’s behavior affect dentists too, and some may be reluctant to see very young children to avoid disruption of the office environment due to crying.(Garg et al. 2013)

From an adult’s perspective a routine dental or medical examination includes procedures that may be uncomfortable but do not elicit a high level of stress. However, child distress during medical and dental procedures is common and likely due to the child’s natural wariness of unfamiliar situations and people, immature communication skills, and developing emotional stability.(Cunha et al. 2009) Medical procedures perceived to be necessary yet painful and distressing to young children, including immunizations, venipuncture, and cancer treatments, have been the subject of extensive investigation.(Blount et al. 1991; Blount et al. 2008b; Chambers et al. 2009; Frank et al. 1995; Mahoney et al. 2010; McMurtry et al. 2007; McMurtry et al. 2010; Zhou et al. 2013) The shared goal of these studies was to identify ways to reduce distress and disruptive behavior of paediatric patients. Recommendations derived from this literature suggest that medical providers’ use of distraction, nonprocedural talk, breathing exercises, specific directions to the child, and physical contact such as bouncing, patting, and rocking may improve a child’s reaction to care. While a considerable body of literature has evaluated pain behavior during routine and specialty medical care, few studies have examined young children’s distress during routine dental care.

Though routine visits rarely include procedures as invasive or painful as an injection, it is widely accepted that young children cry during dental examinations. In fact, parents are sometimes informed that this eventuality is an advantage, allowing for good visualization of the child’s mouth. To date, there have been few studies of the frequency or intensity of distress experienced during dental examination and preventive visits. Interventions to improve the experiences of the parent and child have not been widely considered because we currently have a limited ability to identify children prone to extreme distress during dental examinations. In this study, we sought to quantify the prevalence and intensity of young children’s distress during routine dental examinations and determine if information routinely collected at the time of the appointment could predict the behavior of individual children.

Materials and Methods

Participants

The study was carried out based upon the ethical principles of the Declaration of Helsinki. All procedures were approved by an ethics committee, the University of Washington’s Institutional Review Board (FWA00006878), and each subject’s parent underwent the informed consent process prior to entry into the study. A convenience sample of 122 children presenting to the University of Washington Center for Pediatric Dentistry (CPD) from April 2012 to March 2014 was chosen. Parents of children aged 6 to 36 months who presented for preventive dental examinations were eligible to participate in the study. Subjects were selected from the patient pool of 21 faculty, resident, and student dentist participants. Inclusion criteria were parents fluent in English and physically healthy children under 36 months of age enrolled in the federal government insurance program for low-income children.

Procedures

The data used in this study were collected as part of a larger study of young children’s behavior during dental exams that included video recording of the examination and two questionnaires completed by the parents. For the present study we drew our data from the parent questionnaires only. After check-in with the clinic reception desk, caregivers were approached by a member of the research team and invited to participate in the study. Consenting parents then completed an initial questionnaire. The questionnaires asked for adult and child socio-demographic information; parents’ rating of their child’s health (poor to excellent); parents’ rating of their own dental health (poor to excellent); the age at which the child first had a dental appointment; and the child’s reaction to the last dental examination (easy to difficult). This questionnaire also asked questions pertaining to the child’s reaction to physical exam and shots administered during previous preventive medical visits. Parents rated the intensity of their child’s distress during medical examination on a numerical rating scale, which was later summarized as easy, mid-range, or difficult.

Standard of care preventive dental visit procedures, including an oral examination, prophylaxis, and fluoride varnish treatment were then performed. The majority of children were examined in the knee-to-knee position. During the appointment, parents rated their child’s distress at the following time points: when the dentist entered the room; when the dentist was looking in the child’s mouth, cleaning, or putting fluoride on the teeth; and when the dentist was finished looking in the child’s mouth. The dentist performing the procedures was blinded to the responses of the initial questionnaire and the parent distress ratings. For analysis this was summarized as before, during, and after dental examination, respectively.

In the second questionnaire, procedures were rated by parents on a 10-point numerical rating scale with anchors of “no distress” (0) and “distress as bad as it could be” (10). This measure was informed by clinical studies of pain responses to medical procedures, in which the terms “pain” and behavioral “distress” are used interchangeably.(Cohen 2002; Williamson and Hoggart 2005) Consistent with the literature on pain intensity, the numeric ratings of child distress during the dental appointment were grouped to form a four-level metric: no distress (0), mild distress (1–3), moderate distress (4–6), and severe distress (7+).(Jones et al. 2005)

Statistical Analysis

Descriptive statistics (means, standard deviations, counts, and percentages) were calculated for all variables. Associations among child’s distress during the three parts of the dental appointment (before, during, and after dental examination) were calculated using a Chi-square Test or a Fisher’s Exact Test. Similarly, we tested associations between parent-report of distress during the dental examination and several covariates of interest (child’s age, child’s gender, child and caregiver dental health, caregiver education, and child’s prior experience with preventive dental care) using a Chi-square Test or a Fisher’s Exact Test. The significance level was pre-set to 0.05.

Results

Table 1 presents descriptive information for the 122 parent child dyads that participated in the study. The sample was largely comprised of non-Hispanic white or Asian female caregivers, the majority of whom had attended at least some college. Racial and ethnic characteristics of child participants generally matched that of their adult caregivers. The average age of children enrolled was 23.5 ± 7.3 months, with children between 25–36 months of age representing the largest age group. The majority of parents (80.3%) reported their child’s dental health as good to excellent, while their own dental health was reported as good (45.9%) or worse (24.6%). Nearly all parents (96.7%) reported that their child had a place for medical care, and 56.6% of the children had experienced dental examination previously.

Table 1.

Demographic Characteristics of Adults and the Accompanying Child Participants

N = 122
Caregiver Characteristics
Mean (SD)
Age of Caregiver 31.2 (6.4)
N (%)
Relationship to child
 Mother 93 (76.2%)
 Father 22 (18.0%)
 Other 4 (3.3%)
 Missing 3 (2.5%)
Education
 High School or Less 24 (19.7%)
 Some College 43 (35.2%)
 4 year College or More 51 (41.8%)
 Missing 4 (3.3%)
Hispanic Ethnicity
 Yes 17 (13.9%)
 No 104 (85.3%)
 Missing 1 (0.8%)
Race
 White 75 (61.5%)
 Black 5 (4.1%)
 Asian 19 (15.6%)
 Other/Multiple 12 (9.8%)
 Missing 11 (9.0%)
Overall Dental Health
 Poor/Fair 30 (24.6%)
 Good 56 (45.9%)
 Very Good/Excellent 36 (29.5%)
Amount of Dental Work
 None 24 (19.7%)
 Some 72 (59.0%)
 A lot 25 (20.5%)
 Missing 1 (0.8%)
Child Characteristics
Child Age
 Less than 12 months 7 (5.7%)
 12 – 18 months 23 (18.9%)
 19 – 24 months 31 (25.4%)
 25 months or more 59 (48.4%)
 Missing 2 (1.6%)
Child Gender
 Male 61 (50.0%)
 Female 61 (50.0%)
Child Hispanic Ethnicity
 Yes 24 (19.7%)
 No 96 (78.7%)
 Missing 2 (1.6%)
Child Race
 White 62 (50.8%)
 Black 6 (4.9%)
 Asian 17 (13.9%)
 Other/Multiple 25 (20.5%)
 Missing 12 (9.9%)
Child Has a Place for Medical Care
 Yes 118 (96.7%)
 No 4 (3.3%)
Child Overall Health
 Poor/Fair 3 (2.5%)
 Good 16 (13.1%)
 Very Good/Excellent 102 (83.6%)
 Missing 1 (0.8%)
Child had a Previous Dental Visit
 Yes 69 (56.6%)
 No 51 (41.8%)
 Missing 2 (1.6%)
Child Has a Dental Home
 Yes 103 (84.4%)
 No 19 (15.6%)
Child Overall Dental Health
 Poor/Fair 13 (10.7%)
 Good 41 (33.6%)
 Very Good/Excellent 57 (46.7%)
 Missing 11 (9.0%)
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While about 80% of parents reported their child as having either mild or no distress before the dental examination, almost 55% were reported as displaying moderate or severe distress during the examination procedures. (Figure 1a) Child distress during the examination was statistically associated with distress prior to the dental examination (p<.0001). While a portion of children (28.2%) who displayed no distress pre-examination exhibited severe distress during the examination, most children rated as showing no distress pre-examination were rated as showing no distress, or mild distress, during the examination (56.3%). In contrast, children who exhibited moderate or severe distress pre-examination were highly likely to exhibit severe distress during examination (83.3% and 66.7% respectively). After examination, most children recovered to pre-examination distress levels. Intensity of distress was not associated with age, gender, child or caregiver dental health, caregiver education, or prior experience with preventive dental care. (Table 2)

Figure 1.

Figure 1

Figure 1

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Figure 1a: Child Distress at the Dental Visit

*Graphic created with MS Word

Figure 1b: Child’s Experience at a Medical Visit

*Graphic created with MS Word

Table 2.

Associations Between Caregiver and Child Characteristics and Child Distress During Dental Examination Procedures

Child Distress during Dental Examination p-value
None Mild Moderate Severe
Caregiver Education 0.629*
 High School or less 7 (29.2%) 3 (12.5%) 4 (16.7%) 10 (41.7%)
 Some College 9 (21.4%) 10 (23.8%) 5 (11.9%) 18 (42.9%)
 4 year College or more 8 (16.0%) 13 (26.0%) 11 (22.0%) 18 (36.0%)
Caregiver Overall Dental Health 0.953**
 Poor/Fair 4 (13.3%) 7 (23.3%) 5 (16.7%) 14 (46.7%)
 Good 13 (24.1%) 12 (22.2%) 9 (16.7%) 20 (37.0%)
 Very Good/Excellent 8 (22.2%) 8 (22.2%) 6 (16.7%) 14 (38.9%)
Child Overall Dental Health 0.902*
 Poor/Fair 3 (25.0%) 2 (16.7%) 1 (8.3%) 6 (50.0%)
 Good 9 (22.0%) 6 (14.6%) 9 (22.0%) 17 (41.5%)
 Very Good/Excellent 11 (19.6%) 13 (23.2%) 9 (16.1%) 23 (41.1%)
Child Age 0.620*
 Less than 12 months 2 (33.3%) 1 (16.7%) 1 (16.7%) 2 (33.3%)
 12 – 18 months 3 (13.0%) 8 (34.8%) 4 (17.4%) 8 (34.8%)
 19 – 24 months 5 (16.1%) 5 (16.1%) 4 (12.9%) 17 (54.8%)
 25 months or more 15 (25.9%) 12 (20.7%) 11 (19.0%) 20 (34.5%)
Child Gender 0.504**
 Male 16 (26.2%) 12 (19.7%) 10 (16.4%) 23 (37.7%)
 Female 9 (15.3%) 15 (25.4%) 10 (16.9%) 25 (42.4%)
Child Has Seen a Dentist Previously 0.547**
 Yes 17 (24.6%) 14 (20.3%) 10 (14.5%) 28 (40.6%)
 No 8 (16.3%) 13 (26.5%) 10 (20.4%) 18 (36.7%)
Child Distress Pre Dental Examination <0.001*
 None 24 (33.8%) 16 (22.5%) 11 (15.5%) 20 (28.2%)
 Mild 0 (0%) 9 (36.0%) 7 (28.0%) 9 (36.0%)
 Moderate 1 (5.6%) 1 (5.6%) 1 (5.6%) 16 (83.3%)
 Severe 0 (0%) 1 (16.7%) 1 (16.7%) 4 (66.7%)
Child Difficulty during Medical Examination <0.001*
 Easy 13 (28.9%) 14 (31.1%) 8 (17.8%) 10 (22.2%)
 Mid-Range 10 (18.2%) 12 (21.8%) 11 (20.0%) 22 (40.0%)
 Difficult 0 (0%) 0 (0%) 1 (6.7%) 14 (93.3%)
Child Difficulty during Immunization at Medical Visit <0.001*
 Easy 12 (46.2%) 7 (26.9%) 3 (11.5%) 4 (15.4%)
 Mid-Range 8 (15.4%) 17 (32.7%) 14 (26.9%) 13 (25.0%)
 Difficult 2 (5.6%) 2 (5.6%) 3 (8.3%) 29 (80.6%)
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*

P-value calculated using a Fisher’s Exact Test

**

P-value calculated using a Chi-square Test

While a relatively small number of children were reported to have difficulty with past medical examinations, nearly 1/3 reported difficulty with immunizations. (Figure 1b) Intensity of distress during the dental examination was statistically associated with a history of distress during medical examinations and immunizations (p<.0001). Children reported to have great difficulty with immunizations or with medical examinations were overwhelmingly likely to exhibit severe distress during dental examination (80.6% and 93.3% respectively). (Table 2)

Discussion

In this study, we sought to identify factors related to young children’s distress during preventive oral health visits. Our finding that intensity of distress was not associated with age is surprising, as younger children have previously been reported to demonstrate higher levels of behavioral distress. (Dahlquist et al. 1995) It may be that because all children in our sample were under the age of 36 months, there was insufficient variation to detect an age-based difference. Though approximately half of the children had a history of prior dental visits, this did not appear to positively or negatively affect reported distress.

We found it of interest that only 12% of parents rated their child’s previous medical examinations as difficult and yet more than 3 times that number were rated as displaying severe distress during the dental examination and fluoride application. Because examination and preventive procedures are non-painful, dental providers may presume the infant dental visit to be a relatively benign experience. However, we found that early dental examinations are perceived by parents and very young children to be relatively invasive and sufficiently stressful that stress reduction techniques are indicated.

The medical literature provides insight into practitioner and parent behaviors that may help decrease child stress and facilitate coping. One study that evaluated the influence of adults’ behaviors on infant distress following injections found support for the stress reduction strategies of: distraction, non-procedural talk, and seating the child in contact with the parent. There is also support for parents’ patting the child to promote child coping. (Blount et al. 2008a; Mahoney et al. 2010) Distraction may include use of video, music, or stories during any phase of the visit. Age-appropriate toys such as rattles and dolls can also be useful. (Chambers et al. 2009) These toys can become the focal point of a child-centered approach to dental behavior management. (Weinstein 2008)

While, future research is needed to evaluate the full potential that these techniques have to alleviate stress during the dental examination, practitioners can employ some of these strategies to improve the patient experience. One suggestion is for dental providers to engage in parent coaching: training parents in positioning, body language, distraction techniques, and positive vocal tone. (Chambers et al. 2009) Because parent anxiety is positively associated with negative behavior in children undergoing dental treatment, it may also be wise to inform parents of this and work to reduce their anxiety. Alternately the dentist may suggest that a non-anxious family member bring the child to the appointment. (Frank et al. 1995)

Routine dental care has not traditionally been sought from an early age; however the high rates of decay experienced by young children indicate a need for emphasis in prevention from the time of eruption of the first tooth. While most children see a primary medical care provider approximately 10 times for preventive visits and immunizations before the age of three, few see a dentist in the first years of life.(Douglass et al. 2004) Unfortunately, rates of first dental visits and return visits have been low historically, and remain low. Though additional research is needed to understand low rates of return for ongoing preventive dental care, one possible explanation is related to parents’ satisfaction with the dental experience.(Grembowski and Milgrom 2000) How parents perceive health and illness, preferences for healthcare approaches, and style of communication are also important parental motivators.(Kataoka-Yahiro and Munet-Vilaro 2002; Miller et al. 2010; Vann et al. 2013) In order to foster a habit of routine care it is critical that parents develop positive associations with dentistry and perceive the experience as valuable to their child’s health. By preparing parents for what to expect in a dental examination, clinicians may contribute to a positive association with the visit.

In this study, distress was associated with difficulty during prior medical examinations and immunizations. We found this to be the case for approximately 1/3 of all child participants. These results indicate that children who react most strongly to medical examinations and immunizations are at highest risk for severe distress during dental examination. By inquiring about a child’s reaction to medical procedures the clinician may gain insight into the potential reaction to dental care. This information may then be used to relay accurate messages, set parent expectations, and preempt parent dissatisfaction. Simply asking a question like “how did s/he do for their medical examination?” may go a long way toward predicting the child’s reaction to dental examination. Based upon the large number of children who seem to have a difficult time coping with early preventive dental care, it may also be helpful to explain to parents that dental examination and fluoride treatment is commonly perceived to be relatively invasive. Parents may appreciate knowing that while the majority of children display moderate to severe distress for preventive dental treatment almost all children quickly recover after the examination.

This study was subject to several limitations. Examination procedures were performed at a university-based dental clinic, with twenty-one separate dental providers participating in the project. The treating dentists were comprised of faculty, residents, and students. It is likely that practitioner experience and style may have affected the children’s response to care and parents’ impression of distress experienced by each child. While variation in provider ability is a weakness of the study, it does not significantly detract from the primary outcome of interest: the parent’s subjective assessment of child distress in the context of all medical care. The study provided evidence that many parents perceive early dental visits to be relatively stressful experiences for young children, but child distress was not measured objectively by an independent observer. The study sample was also limited to children from low income families. This group was selected because this population experiences greater difficulty attending preventive dental care and experiences poorer oral health. Although consistent with the intent of the study, this may limit the generalizability of the findings. Parent report was also subject to recall bias, as rating of the child’s distress during medical visit was for past experiences, while the dental examination rating occurred in real time.

Conclusion

This study showed that the majority of parents report that young children experience moderate to severe distress during preventive dental treatment. Pre-examination distress and difficulty with prior medical examinations and immunizations are significantly associated with distress during exam. Parent satisfaction and willingness to bring their child for routine preventive care are impacted by their experience. Dental providers can help parents of young children develop a habit of routine paediatric preventive care by anticipating child behaviors, informing parents about possible child reactions, providing parent coaching, and altering their own style to facilitate a positive experience.

Acknowledgments

This research was supported by grant U54DE019346, National Institute of Health, National Center for Dental and Craniofacial Research. The authors would like to thank Dr. Johan Aps for his critical review of the manuscript.

Footnotes

All authors have made substantive contribution to this study and/or manuscript, and all have reviewed the final paper prior to its submission.

Conflict of Interest:

The authors declare that they have no conflict of interest.

Contributor Information

Travis M. Nelson, Email: tmnelson@uw.edu, Clinical Assistant Professor, Department of Pediatric Dentistry, University of Washington, 6222 NE 74th Street, Seattle, WA 98115, Phone: 206-543-0980, Fax: 206-543-3611.

Colleen E. Huebner, Email: colleenh@uw.edu, Professor of Health Services, School of Public Health and Adjunct Professor of Pediatric Dentistry, School of Dentistry, University of Washington, Box 357230, Seattle, WA 98195.

Amy Kim, Email: akim3@uw.edu, Clinical Assistant Professor, Departments of Pediatric Dentistry and Oral Health Sciences, University of Washington, 6222 NE 74th Street, Seattle, WA 98115.

JoAnna M. Scott, Email: elorra@uw.edu, Acting Assistant Professor, Department of Pediatric Dentistry, University of Washington, 6222 NE 74th Street, Seattle, WA 98115.

Jacqueline E. Pickrell, Email: jpick@u.washington.edu, Lecturer in both the Department of Psychology, and Oral Health Sciences, University of Washington, Box 357574, Seattle, WA 98195.

References

  1. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent. 2012;34(5):148–52. [PubMed] [Google Scholar]
  2. Alio AP, Salihu HM. Maternal determinants of pediatric preventive care utilization among blacks and whites. J Natl Med Assoc. 2005;97(6):792–7. [PMC free article] [PubMed] [Google Scholar]
  3. Beil H, Rozier RG, Preisser JS, Stearns SC, Lee JY. Effects of early dental office visits on dental caries experience. Am J Public Health. 2013 doi: 10.2105/AJPH.2013.301325. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bhaskar V, Mcgraw KA, Divaris K. The importance of preventive dental visits from a young age: Systematic review and current perspectives. In. Clin cosmet investig dent. 2014:21–27. doi: 10.2147/CCIDE.S41499. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bitar King B, Huebner C, Slayton R, Leggott P. Barriers to obtaining needed dental treatment for head start children in washington. University of Washington; 2011. unpublished data. [Google Scholar]
  6. Blount RL, Landolf-Fritsche B, Powers SW, Sturges JW. Differences between high and low coping children and between parent and staff behaviors during painful medical procedures. J Pediatr Psychol. 1991;16(6):795–809. doi: 10.1093/jpepsy/16.6.795. [DOI] [PubMed] [Google Scholar]
  7. Blount RL, Devine KA, Cheng PS, Simons LE, Hayutin L. The impact of adult behaviors and vocalizations on infant distress during immunizations. J Pediatr Psychol. 2008a;33(10):1163–74. doi: 10.1093/jpepsy/jsn030. [DOI] [PubMed] [Google Scholar]
  8. Blount RL, Simons LE, Devine KA, et al. Evidence-based assessment of coping and stress in pediatric psychology. J Pediatr Psychol. 2008b;33(9):1021–45. doi: 10.1093/jpepsy/jsm071. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Canadian Dental Association. Position on first visit to the dentist. Canadian Dental Association; 2005. [Google Scholar]
  10. Chambers CT, Taddio A, Uman LS, Mcmurtry CM. Psychological interventions for reducing pain and distress during routine childhood immunizations: A systematic review. Clin Ther. 2009;31(Suppl 2):S77–s103. doi: 10.1016/j.clinthera.2009.07.023. [DOI] [PubMed] [Google Scholar]
  11. Cohen LL. Reducing infant immunization distress through distraction. Health Psychol. 2002;21(2):207–11. [PubMed] [Google Scholar]
  12. Committee on Oral Health Access to Services, Institute of Medicine. Improving access to oral health care for vulnerable and underserved populations. Washington: The National Academies Press; 2011. pp. 17–39. [Google Scholar]
  13. Cunha RF, Zaze AC, Vieira AE, Melhado FL, Sundefeld ML. Longitudinal behavioral analysis during dental care of children aged 0 to 3 years. Braz Oral Res. 2009;23(3):302–6. doi: 10.1590/s1806-83242009000300013. [DOI] [PubMed] [Google Scholar]
  14. Dahlquist LM, Power TG, Carlson L. Physician and parent behavior during invasive pediatric cancer procedures: Relationships to child behavioral distress. J Pediatr Psychol. 1995;20(4):477–90. doi: 10.1093/jpepsy/20.4.477. [DOI] [PubMed] [Google Scholar]
  15. Darmawikarta D, Chen Y, Carsley S, et al. Factors associated with dental care utilization in early childhood. Pediatrics. 2014 doi: 10.1542/peds.2013-3725. [DOI] [PubMed] [Google Scholar]
  16. Douglass J, Douglass A, Silk A. A practical guide to infant oral health, 2113–20. American Family Physician; 2004. [PubMed] [Google Scholar]
  17. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, Eke PI, Beltran-Aguilar ED, Horowitz AM, Li CH. Trends in oral health status: United states, 1988–1994 and 1999–2004. Vital Health Stat. 2007;11(248):1–92. [PubMed] [Google Scholar]
  18. European Academy of Pediatric Dentistry. Guidelines on prevention of early childhood caries. European Academy of Pediatric Dentistry; 2008. [Google Scholar]
  19. Felber M, Schabmann A, Inschlag N, et al. Effects of parental soothing behavior on stress levels of 2–8 year old children during voiding cystourethrograms by phase of procedure. J Clin Psychol Med Settings. 18(4):400–9. doi: 10.1007/s10880-011-9260-5. [DOI] [PubMed] [Google Scholar]
  20. Frank NC, Blount RL, Smith AJ, Manimala MR, Martin JK. Parent and staff behavior, previous child medical experience, and maternal anxiety as they relate to child procedural distress and coping. J Pediatr Psychol. 1995;20(3):277–89. doi: 10.1093/jpepsy/20.3.277. [DOI] [PubMed] [Google Scholar]
  21. Garg S, Rubin T, Jasek J, et al. How willing are dentists to treat young children?: A survey of dentists affiliated with medicaid managed care in new york city. J Am Dent Assoc. 2010;144(4):416–25. doi: 10.14219/jada.archive.2013.0135. [DOI] [PubMed] [Google Scholar]
  22. Goettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD. Children’s use of dental services: Influence of maternal dental anxiety, attendance pattern, and perception of children’s quality of life. Community Dent Oral Epidemiol. 2012;40(5):451–8. doi: 10.1111/j.1600-0528.2012.00694.x. [DOI] [PubMed] [Google Scholar]
  23. Grembowski D, Milgrom PM. Increasing access to dental care for medicaid preschool children: The access to baby and child dentistry (abcd) program. Public Health Rep. 2000;115(5):448–59. doi: 10.1093/phr/115.5.448. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hale KJ. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5 Pt 1):1113–6. doi: 10.1542/peds.111.5.1113. [DOI] [PubMed] [Google Scholar]
  25. Huebner CE, Bell JF, Reed SC. Receipt of preventive oral health care by u.S. Children: A population-based study of the 2005–2008 medical expenditure panel surveys. Matern Child Health J. 2013;17(9):1582–90. doi: 10.1007/s10995-012-1168-7. [DOI] [PubMed] [Google Scholar]
  26. Jones KR, Fink R, Hutt E, et al. Measuring pain intensity in nursing home residents. J Pain Symptom Manage. 2005;30(6):519–27. doi: 10.1016/j.jpainsymman.2005.05.020. [DOI] [PubMed] [Google Scholar]
  27. Kaste LM, Drury TF, Horowitz AM, Beltran E. An evaluation of nhanes iii estimates of early childhood caries. J Public Health Dent. 1999;59(3):198–200. doi: 10.1111/j.1752-7325.1999.tb03269.x. [DOI] [PubMed] [Google Scholar]
  28. Kataoka-Yahiro MR, Munet-Vilaro F. Barriers to preventive health care for young children. J Am Acad Nurse Pract. 2002;14(2):66–72. doi: 10.1111/j.1745-7599.2002.tb00093.x. [DOI] [PubMed] [Google Scholar]
  29. Kelly S, Binkley C, Neace W, Gale B. Barriers to care-seeking for children’s oral health among low-income caregivers. American Journal of Public Health. 2005 doi: 10.2105/AJPH.2004.045286. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Landers G, Snyder A, Zhou M. Comparing preventive visits of children in foster care with other children in medicaid. J Health Care Poor Underserved. 2013;24(2):802–12. doi: 10.1353/hpu.2013.0066. [DOI] [PubMed] [Google Scholar]
  31. Mahoney L, Ayers S, Seddon P. The association between parent’s and healthcare professional’s behavior and children’s coping and distress during venepuncture. J Pediatr Psychol. 2010;35(9):985–95. doi: 10.1093/jpepsy/jsq009. [DOI] [PubMed] [Google Scholar]
  32. Mcmurtry CM, Mcgrath PJ, Asp E, Chambers CT. Parental reassurance and pediatric procedural pain: A linguistic description. J Pain. 2007;8(2):95–101. doi: 10.1016/j.jpain.2006.05.015. [DOI] [PubMed] [Google Scholar]
  33. Mcmurtry CM, Chambers CT, Mcgrath PJ, Asp E. When “Don’t worry” Communicates fear: Children’s perceptions of parental reassurance and distraction during a painful medical procedure. Pain. 2010;150(1):52–8. doi: 10.1016/j.pain.2010.02.021. [DOI] [PubMed] [Google Scholar]
  34. Milgrom P, Spiekerman C, Grembowski D. Dissatisfaction with dental care among mothers of medicaid-enrolled children. Community Dent Oral Epidemiol. 2008;36(5):451–8. doi: 10.1111/j.1600-0528.2007.00423.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Miller E, Lee JY, Dewalt DA, Vann WF., Jr Impact of caregiver literacy on children’s oral health outcomes. Pediatrics. 2010;126(1):107–14. doi: 10.1542/peds.2009-2887. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Mofidi M, Rozier RG, King RS. Problems with access to dental care for medicaid-insured children: What caregivers think. Am J Public Health. 2002;92(1):53–8. doi: 10.2105/ajph.92.1.53. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Phillips K, Mayer M, Aday L. Barriers to care among racial/ethnic groups under managed care. Health Affairs. 2000 doi: 10.1377/hlthaff.19.4.65. [DOI] [PubMed] [Google Scholar]
  38. Piovesan C, Antunes JL, Guedes RS, Ardenghi TM. Influence of self-perceived oral health and socioeconomic predictors on the utilization of dental care services by schoolchildren. Braz Oral Res. 2011;25(2):143–9. doi: 10.1590/s1806-83242011005000004. [DOI] [PubMed] [Google Scholar]
  39. Savage MF, Lee JY, Kotch JB, Vann WF., Jr Early preventive dental visits: Effects on subsequent utilization and costs. Pediatrics. 2004;114(4):e418–23. doi: 10.1542/peds.2003-0469-F. [DOI] [PubMed] [Google Scholar]
  40. Sen B, Blackburn J, Morrisey MA, et al. Effectiveness of preventive dental visits in reducing nonpreventive dental visits and expenditures. Pediatrics. 2013;131(6):1107–13. doi: 10.1542/peds.2012-2586. [DOI] [PubMed] [Google Scholar]
  41. Smith RG, Lewis CW. Availability of dental appointments for young children in king county, washington: Implications for access to care. Pediatr Dent. 2005;27(3):207–11. [PubMed] [Google Scholar]
  42. Song B, Pickrell J. Research Day Presentation. Seattle, WA: University of Washington; Sep, 2010. Managing children’s dental fear: Current practices in a latino population. [Google Scholar]
  43. US Department of Health and Human Services. Oral health in america: A report of the surgeon general. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. [Google Scholar]
  44. Vann WF, Jr, Divaris K, Gizlice Z, Baker AD, Lee JY. Caregivers’ health literacy and their young children’s oral-health-related expenditures. J Dent Res. 2013;92(7 Suppl):55s–62s. doi: 10.1177/0022034513484335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: Nhanes iii, 1988–1994. J Am Dent Assoc. 1998;129(9):1229–38. doi: 10.14219/jada.archive.1998.0420. [DOI] [PubMed] [Google Scholar]
  46. Watson MR, Manski RJ, Macek MD. The impact of income on children’s and adolescents’ preventive dental visits. J Am Dent Assoc. 2001;132(11):1580–7. doi: 10.14219/jada.archive.2001.0093. quiz 97. [DOI] [PubMed] [Google Scholar]
  47. Weinstein P. Child-centred child management in a changing world. Eur Arch Paediatr Dent. 2008;9(Suppl 1):6–10. doi: 10.1007/BF03262649. [DOI] [PubMed] [Google Scholar]
  48. Williamson A, Hoggart B. Pain: A review of three commonly used pain rating scales. J Clin Nurs. 2005;14(7):798–804. doi: 10.1111/j.1365-2702.2005.01121.x. [DOI] [PubMed] [Google Scholar]
  49. Yu SM, Bellamy HA, Kogan MD, et al. Factors that influence receipt of recommended preventive pediatric health and dental care. Pediatrics. 2002;110(6):e73. doi: 10.1542/peds.110.6.e73. [DOI] [PubMed] [Google Scholar]
  50. Zhou Y, Cameron E, Forbes G, Humphris G. Systematic review of the effect of dental staff behaviour on child dental patient anxiety and behaviour. Patient Educ Couns. 2011;85(1):4–13. doi: 10.1016/j.pec.2010.08.002. [DOI] [PubMed] [Google Scholar]
  51. Zhou Y, Forbes GM, Humphris GM. The behaviour of preschool children receiving fluoride varnish application in a community setting. Br Dent J. 2013;215(7):E11. doi: 10.1038/sj.bdj.2013.990. [DOI] [PubMed] [Google Scholar]

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