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. Author manuscript; available in PMC: 2020 Nov 1.
Published in final edited form as: Int J Paediatr Dent. 2019 Sep 12;29(6):720–727. doi: 10.1111/ipd.12564

Transmission of Dental Fear from Parent to Adolescent in an Appalachian Sample in the USA

Daniel W McNeil 1,2, Cameron L Randall 3, Lindsey L Cohen 4, Richard J Crout 5, Robert J Weyant 6, Katherine Neiswanger 7, Mary L Marazita 8
PMCID: PMC6785362  NIHMSID: NIHMS1042771  PMID: 31328316

Summary

Background:

Dental fear/anxiety are associated with numerous negative outcomes. State dental fear is known to be transmitted from parents to their children in the dental setting, but it is not known how trait fear/anxiety might be shared between parents and offspring long-term, and especially for adolescents.

Aim:

This study aimed to: (a) compare dental fear levels of adolescents and their parents; (b) predict adolescent dental fear based on demographic variables, fear of pain, and parental dental fear; and, (c) determine relative contributions of mothers’ and fathers’ dental fear to adolescent fear.

Design:

In this cross-sectional study, the Dental Fear Survey and Fear of Pain Questionnaire-9 were administered to 350 adolescents (age range 11–17) and 515 of their parents, with t-test and ANOVA used to calculate between-group differences; multiple linear regression was used to predict adolescent fear from parent fear.

Results:

Adolescents’ dental fear was predicted by their own fear of pain and their parents’ dental fear, but not their parents’ fear of pain nor their own age or gender. When considered together, fathers’ but not mothers’ dental fear predicted adolescents’ dental fear.

Conclusions:

Parents’ fears/anxieties about dentistry are associated with adolescents’ dental fear in a manner suggestive of intergenerational transmission.

Keywords: dental fear, dental anxiety, fear of pain, adolescence, parents

Introduction

The relation between dental fear in children and their parents or other caregivers has been investigated for over a century1 and the “parental pathway” is considered to be one of the primary routes of dental fear acquisition in children2. In the broader fear and anxiety literature, specific fears and phobias have been found to some degree to be transmitted in families, with an underlying vulnerability that may be genetically determined in certain individuals and with neural mechanisms potentially underpinning vicarious fear learning in the developing brain3,4. Social learning and other theories suggest that the transmission of anxiety, fear, and other emotional states—as well as coping strategies—to youth by those in their environment occurs through modeling and direct instruction5. While direct conditioning6 and child temperament7 certainly are contributing factors, having a family member with high dental fear has been found to predict onset of high dental fear or phobia in childhood5,6,8 and is one of the predictive factors of dental phobia in adults9.

Both acute, context-specific fearfulness (i.e., “state”) and stable fearful/anxious tendencies (i.e., “trait”) are potentially important here. Parents and other caregivers can impact the behaviour, including fearful/anxious behaviour, of their children in the immediate situation in the dental operatory, for example, by articulation of more or less helpful comments10. Moreover, parents impact their children’s values, views, and behaviour regarding dental care in numerous ways in everyday life outside of the operatory, by their own behaviour (i.e., modeling), and through direct instruction, in what they tell them about dental care and its importance1.

With regard to intergenerational transmission of dental fear and anxiety, specifically, the greatest focus in the literature thus far has been on mothers, and on young children1. The few studies comparing the strength of mother-child and father-child dental fear associations in two-parent, heterosexual families showed the mother-child association to be stronger than the father-child association11–14. Only one known study has specifically addressed the contribution of mothers’ versus fathers’ fear on child dental fear level and suggested a mediational role of fathers’ dental fear in the association between mother and child fear/anxiety15. This limited and mixed literature includes only children aged 13 years and younger.

The age of onset of high levels of dental fear/anxiety, and its pathological manifestations in phobia, is of some importance developmentally. Over 70% of high dental fear or phobia begins in childhood or adolescence, although it can originate during adulthood as well8. A meta-analytic review1 demonstrated a positive relation between parent and child dental fear/anxiety, but more convincingly in children who are eight years old and younger. The impact of parental/caregiver dental fear/anxiety on offspring/dependents during adolescence is less clear, and so is in need of further investigation. Adolescence may represent a developmental period during which dental fear/anxiety can have a disproportionate influence on future dental attendance or avoidance behaviour, as has been shown in medical settings16. It is worth studying dental fear/anxiety in adolescence given that it is a critical period for the development of independence in decision making and because control emerges during this period as a key influencer of dental fear/anxiety17, complicating its etiology and potential impact on future dental treatment-seeking behaviour.

To more fully understand adolescent dental fear/anxiety, examination of parent dental fear/anxiety is critical. Parents’ dental fears, anxieties, attitudes, and experiences affect their children’s dental comfort or fears/anxieties1,9. Moreover, parents’ dental fear/anxiety can influence their children’s dental care attendance in that highly fearful/anxious parents may be more likely to not follow through on their children’s scheduled appointments, or may fail to schedule regular checkups. Given the studies indicating that many dental fears/anxieties peak in childhood and adolescence and often remain constant in adulthood18,19 and then decline with increasing age, it might be expected that children would have higher dental fear/anxiety than their parents. On the other hand, current dental educational efforts in schools and in the mass media, greater and earlier access to oral health care, and improved (“painless”) technologies in dentistry might have a positive impact and result in children reporting fewer dental fears/anxieties than their parents. Nevertheless, the dental fear levels of the adult population in the USA appear to have remained constant since the 1960s20. Gender differences might also be evident in adolescent as in adult dental fear/anxiety; in most studies, women report more and men report less dental fear/anxiety20,21. Such differences, observed for numerous types of fears, likely are related to gender roles and socialization, but may differ developmentally22,23.

Whereas dental fear, anxiety, and phobia in general have been a major research area historically24, these phenomena in developing nations, as well as in underserved regions such as Appalachia in the USA, has been less of a focus, with few exceptions25. Including parts of 12 eastern USA states plus the entire state of West Virginia, Appalachia is comprised of 530,948 sq km; 42% of Appalachia’s population is rural, relative to 20% across the USA as a whole26. It is likely that the unique psychosocial factors related to living in isolated parts of Appalachia and other rural areas globally influence oral health care. For instance, geographic isolation, topographic and weather-related travel barriers, economic issues, and a set of values emphasizing self-reliance and non-interference with others likely affect the development and manifestation of fear, anxiety, and ultimately health care utilization27,28. Given that high dental fear/anxiety and phobia predict avoidance of oral health care18,29, and that there are disproportionately high rates of oral health problems in Appalachian and other rural populations30, it is particularly important to examine dental fears/anxieties in Appalachian families.

As with other types of fear and anxiety31, the present study conceptualized “dental care-related fear and anxiety” as existing along a continuum, ranging from no fear to psychopathological manifestations (dental phobia), and not as a binary phenomenon (i.e., fear or no fear), and not only as a discrete disease state32. The terminology in this area is imprecise, and the phrases “dental fear” and “dental anxiety” often are used interchangeably, although research suggests differences between these two constructs in terms of fears and anxieties, generally, and in terms of dental fear and dental anxiety, specifically33. As a related concept, fear of pain has been shown to be a major component of dental fear/anxiety in many individuals34, and to be an important factor in dental pain research35. Having experienced pain during dental treatment is associated with later dental fear/anxiety in children36.

In the present study, we examined and compared the dental fear/anxiety levels of parents and their adolescent children in North Central Appalachia. Families in Appalachia are important to assess, given the disproportionately high rates of oral disease in this population30. Differences in dental fear/anxiety levels between parents and adolescents were predicted, but non-directionally, as both higher and lower levels for each group potentially could be anticipated. Sex differences were anticipated, with females reporting higher levels and males reporting lower levels of dental fear/anxiety. It was expected that dental fear/anxiety in adolescents would be predicted by their own fear of pain and parental levels of dental fear/anxiety and fear of pain. Additionally, consistent with previous literature summarized above, it was anticipated that fathers’ dental fear/anxiety would predict adolescent dental fear over and above mothers’ fear/anxiety. To our knowledge, this is the first study to determine the relative contributions of fathers’ and mothers’ dental fear/anxiety to adolescent dental fear, and the first to quantify such associations in a sample from the USA.

Material and Methods

Participants

The current investigation utilizes data from the Center for Oral Health Research in Appalachia’s family-based study on determinants of oral diseases (first cohort; COHRA1)30,37. The COHRA1 study invited the enrollment of all members of any household comprised of at least one participating biological parent-child (i.e., age 1–18 years) pair. Inclusion criteria were: (a) being part of a biological parent-child dyad that lived together in the same household, or a member of that household regardless of biological or legal relationship; and, (b) having permanent residence in the targeted recruitment areas (Webster and Nicholas counties in West Virginia, USA; Allegheny, Washington, and McKean counties in Pennsylvania, USA). Given that the COHRA1 study protocol involved interviews and questionnaire batteries, clinical examinations, and biospecimen collection, exclusion criteria were: (a) having neurological impairment, a severe physical or intellectual handicap, or psychosis; and (b) being any member of a family that included as part of the biological parent-child dyad someone who had reduced capacity to fight infection or reduced ability to form blood clots.

COHRA1 study participants were included in the current investigation if they: (a) were an adolescent aged 11–17 years with whom at least one biological parent also participated, or the biological parent of a participating adolescent; and (b) had completed the assessments of dental fear/anxiety and fear of pain. Thus, the results presented here describe data for 350 adolescents (50% female; M age = 13.5 years, SD = 1.8). Consistent with the racial/ethnic makeup of this North Central Appalachian community, most adolescent participants were White (n = 281; 80%); approximately 16% (n = 55) of the sample was African American / Black, 1% (n = 3) was Hispanic, and 1% (n = 2) was Asian, with approximately 2% (n = 8) identifying as more than one race (race/ethnicity data missing for 1 participant). Data from both biological mother and father were available for 165 (47%) adolescent participants, with data from only biological mothers available for 173 (50%), and only biological fathers available for 12 (3%).

Measures

Demographic and health history interview.

A structured interview was conducted to obtain demographic information (e.g., sex, age, race/ethnicity) and a health history of the family, among other information. Parents and adolescents separately answered questions about demographic and health/habit variables.

Dental Fear and Anxiety.

The Dental Fear Survey (DFS39) is a 20-item self-report instrument utilizing a 1–5 Likert-type scale for responding; greater scores indicate higher levels of dental fear. The instrument has psychometric data attesting to its validity and reliability40. It has been used with a variety of adolescent and adult populations, as well as across a diversity of cultural groups in the USA and internationally41. In addition to a total score, there are three subscale scores: (a) Avoidance/Anticipatory Fear (8 items), (b) Fear of Specific Dental Stimuli (6 items), and (c) Physiological Arousal (5 items).

Fear of Pain.

General fearfulness about pain was assessed with the Fear of Pain Questionnaire – 9 (FPQ-942). The FPQ-9, a shortened version of the reliable and valid Fear of Pain Questionnaire – III43,44, assesses fear about pain across a variety of events, and is suitable for use in both adult and adolescent populations. This scale can be used regardless of whether or not an individual is experiencing acute or chronic pain. There are three factorially-derived subscales: (a) Fear of Dental/Medical Pain, (b) Fear of Severe Pain, and (c) Fear of Minor Pain; a total score also can be derived. There is support for the validity of the FPQ-9; it has been tested psychometrically and has been found to have good internal consistency and test-retest reliability42.

Procedure

Participants were community volunteers from Appalachian communities in West Virginia and Pennsylvania who were recruited using a household-based approach. Additional details about the study protocol and sample have been published elsewhere37,38.

This study was approved by the Institutional Review Boards at West Virginia University and the University of Pittsburgh. All adult participants gave written informed consent for involvement in this study; adolescents gave written assent along with written parental informed consent for their participation. Participants received monetary compensation for time and reimbursement for travel costs. Questionnaire administration was completed independently by parents and adolescents; in cases in which there was difficulty with reading, a research assistant helped the participant to complete the questionnaires. Along with questionnaire administration, participants completed a variety of other assessments, including an oral health examination, as part of the larger COHRA1 protocol37, with the intention of establishing the extent of the problems and of helping to define the pathways that lead to oral health or disease in Appalachia30,37.

Statistical Approach

Missing questionnaire data were replaced using mean imputation; no participant was missing data for more than 20% of DFS or FPQ-9 items. To represent parent data generally, in instances in which DFS and FPQ-9 data were available for both parents of a participating adolescent, their scores on each measure were averaged to yield a single value for analyses. If only one parent was involved, then those single scores served as the data. Student’s t-tests and Analysis of Variance (ANOVA) with Tukey’s HSD post-hoc test were used to test for between-group differences in DFS and FPQ-9 scores. Multiple linear regression was used to predict adolescent DFS and FPQ-9 scores based on parent scores on the same instruments. All statistical analyses were carried out using SPSS 21(IBM; Armonk, NY).

Results

Differences in Dental Fear and Fear of Pain Levels

Mean DFS and FPQ-9 scores are summarized in Table 1. There was a significant main effect of adolescent/parent status on dental fear/anxiety level, F(2,862) = 26.86, p < .0001. Adolescents reported significantly lower dental fear/anxiety than their fathers, which was significantly lower than the report by their mothers. There also was a significant main effect of adolescent/parent status on level of fear of pain, F(2,862) = 10.40, p < .0001, with adolescents reporting lower levels of fear of pain than their mothers, and higher—but not significantly—than their fathers. In general, adolescents had significantly lower DFS (M = 33.3, SD = 14.4) scores than parents (M = 41.3, SD = 18.1), t(698) = 6.45, p < .0001. The same trend was observed for FPQ-9 scores, however, the difference was not significant.

Table 1.

Dental Fear Survey and Fear of Pain Questionnaire-9 Means and Standard Deviations by Group.

Adolescents (n = 350) Mothers (n = 338) Fathers (n = 177)
Measure M SD M SD M SD
DFS
 Total Score 33.3a 14.4 43.4b 20.8 37.3c 19.0
 Avoidance/Anticipatory Fear 11.2a 5.4 14.8b 8.3 12.9c 7.3
 Specific Dental Stimuli 13.1a 7.0 16.4b 8.0 13.9a 7.5
 Physiological Arousal 7.3a 3.3 9.9b 5.3 8.5c 4.4
FPQ-9
 Total Score 23.6a 8.4 25.7b 7.9 22.5a 8.2
 Fear of Minor Pain 6.0a 2.9 6.5b 2.6 6.0a 2.3
 Fear of Severe Pain 9.5a 3.6 10.7b 3.5 9.4a 3.8
 Fear of Medical/Dental Pain 8.1a 3.6 8.4a 3.3 7.1b 3.4
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Note. N = 865. Means in the same row with different superscripts are significantly different, p < .05. DFS is the Dental Fear Survey; FPQ-9 is the Fear of Pain Questionnaire-9.

Female (DFS M = 34.5, SD = 15.2) and male (M = 32.1, SD = 13.6) adolescents did not differ significantly in their report of dental fear/anxiety; however, female adolescents reported higher (FPQ-9 M = 25.0, SD = 8.1) and male adolescents reported lower (M = 22.2, SD = 8.5) levels of fear of pain, t(348) = 3.20, p = .002. In the case of dental fear/anxiety, mothers reported higher (DFS M = 43.4, SD = 20.8) and fathers reported lower (M = 37.3, SD = 19.0) levels, t(513) = 3.26, p = .001. Likewise, mothers reported greater levels (FPQ-9 M = 25.7, SD = 7.9) and fathers reported lower levels (M = 22.5, SD = 8.2) of fear of pain, t(513) = 4.39, p = .0001.

Prediction of Adolescent Dental Fear

Linear regression analyses were conducted to predict dental fear/anxiety levels in adolescents. Groups of variables were sequentially blocked to ascertain the contribution of each conceptual area, and to first determine any effects related to demographics: (a) age and gender, (b) youth’s fear of pain levels, (c) parent dental fear/anxiety levels, and (d) parent fear of pain levels. Table 2 presents the results of this regression analysis, indicating the significant contributions of parental dental fears/anxieties and the adolescents’ own fear of pain, but not parental fear of pain nor adolescents’ age and gender, to adolescent dental fear. The overall model is significant, F(5,344) = 22.23, p < .001, explaining 24% of the variance in adolescent dental fear/anxiety observed in this sample.

Table 2.

Linear Regression Model Predicting Adolescent Dental Fear Survey Score

Step Predictor Variable Standardized Regression Coefficient (β) Significance Value (p) R2 Increase in R2
1 Adolescent Gender .08 .125 .009 .009
Adolescent Age .05 .383
2 Adolescent FPQ-9 Score .45 < .001 .206 .197
3 Parent DFS Score .193 < .001 .242 .036
4 Parent FPQ-9 Score .05 .346 .244 .002
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Note. n = 350 adolescents. FPQ-9 is the Fear of Pain Questionnaire-9; DFS is the Dental Fear Survey.

Prediction of Adolescent Dental Fear/Anxiety from Mother and Father Dental Fear/Anxiety

For adolescents in the sample for whom both biological mother and father participated in dental fear/anxiety measurement (n = 165), linear regression analyses were conducted to determine the unique contribution of mother versus father dental fear/anxiety to adolescent dental fear levels. Table 3 presents the results of this regression analysis. When fathers’ DFS score is entered into the model, mothers’ DFS score no longer is a significant predictor of adolescent DFS score. The overall model is significant, F(2,162) = 6.09, p = .003, and explains 7% of the variance in adolescent dental fear.

Table 3.

Linear Regression Model Predicting Adolescent Dental Fear Survey Score

Step Predictor Variable Standardized Regression Coefficient (β) Significance Value (p) R2 Increase in R2
1 Mother’s DFS Score .15 .049 .02 .02
2 Mother’s DFS Score .10 .204
Father’s DFS Score .22 .005 .07 .05
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Note. n = 350 adolescents. FPQ-9 is the Fear of Pain Questionnaire-9; DFS is the Dental Fear Survey.

Discussion

We discovered that adolescents’ dental fear/anxiety was related to parental dental fear/anxiety at a trait level, providing additional evidence for intergenerational transmission of dental fear/anxiety that persists at least into adolescence. Unsurprisingly, adolescents’ own fear of pain and parental dental fear predicted adolescent dental fear/anxiety level. Surprisingly, however, parental fear of pain did not predict adolescent dental fear/anxiety level.

Ours is the first study to address the unique roles of mothers and fathers in the intergenerational transmission of dental fear in a sample from the USA and, importantly, in a sample of adolescents. Most interesting was our finding that, when accounted for separately and concurrently, fathers’ but not mothers’ dental fear predicts adolescent dental fear/anxiety. This finding is consistent with the only other known study assessing relative contributions of mothers’ and fathers’ dental fears/anxieties to their (younger) children’s dental fear15, as well as a study suggesting that fathers’ dental fear/anxiety is one of the best predictors of potential child dental fear/anxiety45. Our study provides support for this phenomenon occurring not only in childhood but also in adolescence. As proposed by Lara and colleagues15, the mediating role of fathers’ dental fear/anxiety in the relation between mother and child dental fear/anxiety may suggest that fathers play a key role in the emotional transfer of dental fear/anxiety. Because women generally tend to be more emotionally expressive than men (i.e., not necessarily more emotional, but more inclined to communicate it)23,46,47, children’s observation of emotional expression in their father (e.g., dental fear/anxiety) may offer a particularly salient “warning” of threat. Additional research is needed to comprehensively understand why fathers’ dental fear/anxiety is a more robust predictor of child fear/anxiety and whether fathers’ and mothers’ fears/anxieties play different roles at different developmental periods, as current data allow only speculation.

The differences between dental fear/anxiety levels of the adolescents and their parents are noteworthy. Given that dental fear/anxiety is predictive of dental care behavior, it may be encouraging that Appalachian youth are less fearful of dentistry than their parents. It is possible that this difference suggests a trend toward lower fear/anxiety of dental health care in these youth. If so, this positive trajectory might be related to educational and media attempts to minimize dental fear/anxiety, more “painless” dental techniques, less traumatic history of dental care, or other factors. Nevertheless, it is unknown whether or not study findings are unique to Appalachia, or unique to influences from parents, apart from grandparents, aunts and uncles, other extended family and caregivers. It may be that there are developmental issues affecting young people of many cultural groups that predispose them to report less fear during adolescence.

We also found that, in adolescents, gender differences in the report of dental fear/anxiety—typically women higher and men lower—were not as robust as in some other studies, and indeed non-significant in ours. In this Appalachian sample, there may be cultural variables that contribute to a lessening of gender differences seen in other groups. Alternatively, the specific age cohorts in the current study may have affected these results.

The participant sample, coming from North Central Appalachia, is both a strength and a limitation of this study. This group, of course, cannot be seen as representing all of Appalachia, nor all rural or underserved groups in the USA or internationally. Nevertheless, as a distinct cultural group beset by numerous oral and other health problems, disparate from the USA population as a whole, there are implications for underserved groups and regions in other developed nations and in developing countries, generally. This investigation is further strengthened by the use of standardized, validated psychometric instruments with the same scales utilized by both parents and adolescents; this use of such tools in this manner has been inconsistent in the literature1. Past research has focused in part on the setting in which the dental fears of parents and children has been assessed1. This study, however, highlights a state-trait distinction in anxiety and fear, focusing on enduring behavioral tendencies/probabilities (i.e., traits). Much prior research has emphasized acute (i.e., state) influences of parental dental fear1.

A key limitation of this study was that only approximately half of the adolescent sample had two participating parents and, given the data source, it is not possible to know whether the others were reared in single-parent families or whether one parent simply did not participate in the study. As such, results related to relative contributions of mothers’ versus fathers’ dental fears/anxieties on adolescent fear/anxiety may be biased, Additionally, given the cross-sectional nature of the study, it is not possible to know whether intergenerational transmission of dental fear/anxiety observed in adolescence occurs in adolescence, earlier in childhood, or across developmental periods. Longitudinal work is needed. The current study also was not able to examine whether fear/anxiety in this sample predicts future improved oral health behaviour, and how it might change over time. In fact, fear/anxiety levels might increase as adolescents leave home and it becomes necessary for them to take on greater responsibility for arranging their own oral health care. Further, greater experience with uncomfortable dental procedures, and the possibility of increased numbers of oral health problems with increasing age, may be associated with increasing fear as they enter adulthood.

This study is one of only a few to demonstrate associations between parental dental fear/anxiety and adolescent dental fear/anxiety. Moreover, it demonstrates a potentially unique role of paternal versus maternal dental fear/anxiety in offspring dental fear etiology. Future studies should address how unique characteristics of adolescence may facilitate intergenerational transmission of dental fear/anxiety and whether vicarious learning and/or other mechanisms are etiologically important during this important developmental period. Future work also should seek to elucidate how maternal versus paternal transmission pathways differ. Results of such studies may provide targets for future interventions that prevent the persistence of dental fear/anxiety from childhood to adulthood and the translation of childhood fears/anxieties to fears/anxieties in adulthood that are behaviorally and health impairing.

Bullet Points.

Why this paper is important to paediatric dentists:

  • When addressing high levels of dental fear, anxiety, and phobia in adolescents, paediatric dental providers should consider the role of parents and caregivers in the etiology and maintenance of these problems, given the possibility of intergenerational transmission.

  • The role of fathers’ dental fear and anxiety, which heretofore has scarcely been considered, is highly relevant factor in adolescent dental fear and anxiety.

  • Fear of pain is an important etiological component of dental fear, anxiety, and phobia in adolescents, as it is in adults.

Acknowledgements

The authors thank all of the members of the participating families for joining the study and for their support for enhancing oral and overall health in rural communities in West Virginia, Pennsylvania, and elsewhere in Appalachia. The research teams in West Virginia (Linda J. Brown, Dr. Elizabeth Kao, Natalie A. Marquart, Aliyah Pugh, Karolyn Ruggles, Tayla Tallman, and Ella “Barb” Thaxton) and Pennsylvania (Jill Beach, Wendy Carricato, Zelda Dahl, Tonya Dixon, Jessica Ferraro, Jennifer Maurer, Chika Richter, Alicia Wicks, Lauren Winter, and Jayme Zovko), past and present, worked tirelessly to collect and manage the data on which this study is based. The West Virginia Rural Health Education Partnerships program provided an overall framework for the conduct of this study; Hilda Heady was instrumental in supporting this research. The Webster-Nicholas Health Education Partnerships Board served as a community advisory board. Cierra Brooks Edwards provided comments on an earlier draft of this paper.

This study was partially supported by grants from the National Institute for Dental and Craniofacial Research / National Institutes of Health (R01 DE014899 and R21 DE026540), and by research development funds from the University of Pittsburgh School of Dental Medicine, the West Virginia University School of Dentistry University Health Associates Research Fund, the Robert C. Byrd Health Sciences Center, and the West Virginia University Eberly College of Arts and Sciences. The authors declare no conflicts of interest.

Contributor Information

Daniel W. McNeil, Clinical Professor, Department of Dental Practice & Rural Health;; Professor, Department of Psychology, Eberly Distinguished Professor, Eberly College of Arts and Sciences, West Virginia University, Center for Oral Health Research in Appalachia

Cameron L. Randall, Department of Oral Health Sciences, University of Washington School of Dentistry, Center for Oral Health Research in Appalachia.

Lindsey L. Cohen, Department of Psychology, Georgia State University.

Richard J. Crout, Department of Periodontics, School of Dentistry, West Virginia University, Center for Oral Health Research in Appalachia.

Robert. J. Weyant, Department of Dental Public Health and Information Management, School of Dental Medicine, University of Pittsburgh, Center for Oral Health Research in Appalachia.

Katherine Neiswanger, Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Center for Oral Health Research in Appalachia.

Mary L. Marazita, Director, Center for Craniofacial and Dental Genetics, and Professor, Department of Oral Biology, School of Dental Medicine; Professor, Department of Human Genetics, Graduate School of Public Health; and Professor, Clinical and Translational Science and Department of Psychiatry University of Pittsburgh, Center for Oral Health Research in Appalachia.

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