Abstract
Objective:
Dental fear screening is an important part of providing a positive pediatric dental experience. To improve efficiency, the development of a single-item dental fear assessment tool for children has been desired. In this psychometric analysis, the reliability and validity of the Dental Anxiety Question (DAQ) is studied when used in children aged 7 to 18 years.
Methods:
Participants completed the DAQ (pre-tx-DAQ), the Children's Fear Survey Schedule–Dental Subscale (CFSS-DS), and a demographic information questionnaire before treatment. Participants repeated the DAQ after treatment (post-tx-DAQ) and once more at least 2 weeks later (follow-up-DAQ). Stability reliability within the DAQ scores and criterion validity with the CFSS-DS were evaluated.
Results:
Stability reliability analyses between pre-tx-DAQ/post-tx-DAQ and post-tx-DAQ/follow-up-DAQ demonstrated significant positive correlations: Spearman rank correlation coefficient (rs) = 0.420, rs2 = 0.18, P < .001, and rs = 0.563, rs2 = 0.32, P < .001, respectively. Criterion validity analysis between the pre-tx-DAQ and CFSS-DS also demonstrated a significant correlation: Pearson correlation coefficient (r) = 0.584, r2 = 0.34, P < .001.
Conclusion:
The stability reliability and criterion validity of the DAQ was proved among children.
Keywords: Dental anxiety; Surveys; Questionnaires, Reproducibility of results; Fear; Reliability; Validity; Dental Anxiety Question; Children's Fear Survey Schedule–Dental Subscale; Frankl scale
Dental care–related fear and anxiety (ie, dental fear)1 prevent regular dental checkups, which can result in poor oral health and a decreased quality of life.2–6 Many adults with dental fear recall a traumatic experience during their childhood as the origin of their dental fear.7,8 Dentists caring for children play an important role in preventing traumatic dental experiences9 and should assess dental fear levels before treatment begins.
A dental fear questionnaire for children, the Children's Fear Survey Schedule–Dental Subscale (CFSS-DS),10 has been adopted in many different languages with strong reliability and validity and is the most frequently used questionnaire in the world.11–15 However, one of the main problems with the CFSS-DS is that it consists of multiple (currently 15) items. The best time to conduct dental fear screening is before exposing the patient to any dental equipment, ideally during the patient registration process. However, parents already complete several forms during registration, such as insurance, general health, and demographic information. Dentists also need time to interpret the multi-item dental fear questionnaire. Thus, it is not easy to add a multi-item dental fear screening questionnaire such as the CFSS-DS.
Several single-item dental fear questions and surveys have been developed.16–19 Although their reliability and validity have been tested and good outcomes reported, the research populations consisted primarily of adults. Some single-item measures, such as the Dental Anxiety Question (DAQ),19 were administered to children and indicated reasonable results.4,20 However, psychometric analysis has never been performed on such tests given to children. Based on our systematic literature review, we found no articles studying the reliability and validity of the DAQ administered to children. Although there is no research to determine which single-item survey is the best for children, the DAQ seems to be used more frequently in research projects compared with other single-item questions or surveys.
The primary aim of this research was to assess the psychometric properties, specifically the test-retest (ie, stability) reliability, criterion validity, and predictive validity, of the DAQ administered to pediatric patients.
METHODS AND MATERIALS
This study was conducted using a mixed cross-sectional and longitudinal design to assess the stability reliability and criterion and predictive validity of the DAQ in children. It was approved by the University Hospitals Institutional Research Board (IRB) and was conducted from January 2017 to December 2018. Participants were recruited from patients visiting the Irving and Jeanne Tapper Dental Center at University Hospitals Rainbow Babies & Children's Hospital, an urban hospital-based pediatric dental clinic in Cleveland, Ohio. Recruitment was not randomized, and all pediatric patients (7 to 18 years of age) who visited the clinic for invasive treatment (eg, restorations, crowns, pulpotomies, and extractions) were invited to participate. Exclusion criteria included patients who required sedation for treatment or those with mental illness or disorders who were unable to reliably answer the questions.
The following measurement tools were used for this study: the DAQ, the CFSS-DS, Frankl's behavioral rating scale (see the Appendix), and a patient demographic questionnaire.
DAQ
Developed in 1990 by Neverlien, the DAQ is a single-item dental anxiety measure that uses a 4-point Likert-type scale and simply asks, “Are you afraid of going to the dentist?”19 The DAQ has demonstrated validity with adult patients. Statistical analyses conducted between the DAQ and the total score of the Dental Anxiety Scale, frequently used to measure dental anxiety globally as well as each individual item, have yielded significant positive correlations.19 Compared with other single-item dental fear questionnaires, it seems that the DAQ is easier for young children to answer despite their inexperience and general lack of familiarity with dentistry.
CFSS-DS
Developed by Cuthbert and Melamed in 1982,10 the CFSS-DS consists of 15 items with 5-point Likert-type scales. The total scores range from 15 to 75, with a higher score indicating higher levels of dental fear. It has been used as a standard dental fear questionnaire for children and has been adapted to many different languages, including Greek11 and Japanese.14 In this study, the CFSS-DS data were collected prior to treatment to assess participant dental fear levels.
Frankl's Behavior Rating Scale (Frankl Scale)
The Frankl scale is an ordinal scale with 4 ratings used to describe a child's behavior from definitely negative (1), negative (2), positive (3), and definitely positive (4).9 Observed refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme negativism is scored a 1. Observed reluctance to accept treatment and uncooperative behavior with some evidence of negative but not pronounced attitude is scored a 2. Observed acceptance of treatment, cautious behavior at times, and willingness to comply with the dentist's directions cooperatively at times with reservation is scored a 3. Observed good rapport with the dentist, interest in the dental procedures, laughter, and enjoyment is scored a 4. Scores are often used to help determine appropriate treatment modalities and set realistic expectations for future appointments. A Frankl rating score was assigned by each pediatric dentist immediately after treatment to assess dental fear–related behavior during the participant's care and is a routine assessment at our clinic.
Questionnaire for Demographic Information
This questionnaire inquired about participant ethnicity, race, age, and sex.
Study Procedures
After obtaining paper copies of parental consent and patient's assent as required by IRB regulations, the child participants and their parents were asked to complete paper copies of the DAQ (pre-tx-DAQ), the CFSS-DS, and the demographic information questionnaire in an operatory before their dental treatment was performed by pediatric dentists or dental residents. At the end of their appointment, participants were again asked to complete the DAQ (post-tx-DAQ) in the same manner as before.
The pediatric dentist providing or supervising the child's treatment rated their behavior using the Frankl scale and included that scoring as part of the routine charting. Frankl scores were transferred into the study's database after charting for the patient's visit was completed by the treating dentist or resident. Researchers contacted participants by phone 2 weeks after their appointments to repeat the DAQ (follow-up-DAQ). If participants were unavailable, researchers called again later. Double data entering and other human errors were reviewed and corrected to increase database accuracy.
Statistical and Power Analyses
Pearson correlation was used for the analysis of stability reliability performed between the pre-tx-DAQ/post-tx-DAQ and the post-tx-DAQ/follow-up-DAQ data. Criterion validity was assessed between pre-tx-DAQ and CFSS-DS data using Pearson correlation. Predictive validity of the Frankl scale rating was compared with the CFSS-DS using Pearson correlation (r) and with the pre-tx-DAQ using Spearman correlation (rs). As the post-tx-DAQ and follow-up-DAQ were answered after the invasive treatment and could differ from the pre-tx-DAQ, Spearman correlation tests were also performed for the post-tx-DAQ and follow-up-DAQ with the Frankl scale. Finally, a linear regression analysis was conducted for pre-tx-DAQ using age, sex, ethnicity, race, and the CFSS-DS as predictors.
Following an independent pilot test (n = 30), the sample size was calculated and monitored by using the statistical power for the stability and criterion validity of the DAQ. An a priori power analysis was performed using an alpha of .05, a beta of 80%, and an effect size of r > 0.3, which generated a total of 80 required subjects. All statistical analyses were performed using IBM SPSS statistics 26.
RESULTS
The total number of enrolled participants was 79, with 2 excluded from the statistical analyses because of a lack of post-tx-DAQ and follow-up-DAQ data. Sixty-one participants (79.2%) answered the follow-up-DAQ. With regard to the duration of follow-up, 50% occurred within 30 days, although the maximum duration was 607 days.
Table 1 shows the participants' demographic information, follow-up time point, and information of the participants who dropped out of the follow-up data collection. The study site was in an urban area with a predominantly Black population. The percentage of Black patients was 72.7%, White was 15.6%, and other or multiple races was 9.1%, including 1 American Indian or Alaskan Native participant and 1 Asian participant. There was no statistically significant difference in the demographic information between participants who followed up versus those who did not.
Table 1.
Participants' Demographic Information
|
Demographic variable
|
Pre- and posttreatment, n = 77
|
Follow-up, n = 61
|
Dropouts, n = 18
|
| Age, y, mean (SD) | 10.02 (2.60) | 10.13 (2.65) | 9.51 (2.41) |
| Sex, male/female | 37/39 | 27/33 | 11/7 |
| Ethnicity, non-Hispanic or non-Latino/Hispanic or Latino/unknown | 70/3/4 | 55/3/3 | 17/0/1 |
| Race | |||
| Black | 56 | 43 | 14 |
| White | 12 | 9 | 4 |
| Other or multiple* | 9 | 9 | 0 |
Included American Indian or Alaskan Native or Asian. No other races participated.
Table 2 shows the distribution of dental fear–related variables; pre-tx-, post-tx-, and follow-up-DAQ; CFSS-DS; and Frankl scale. There was no significant difference in the series of pre-tx-, post-tx-, and follow-up-DAQ (Friedman ranking test, chi-square = 1.456, df = 2, P = .483).
Table 2.
Distribution of Dental Fear–Related Variables
|
|
Pretreatment
|
Posttreatment
|
Follow-up
|
| DAQ score, n (%) | |||
| 1, No | 52 (67.5) | 55 (71.4) | 41 (67.2) |
| 2, A little | 12 (15.6) | 14 (18.2) | 15 (24.6) |
| 3, Yes, quite | 8 (10.4) | 1 (1.3) | 3 (4.9) |
| 4, Yes, very | 5 (6.5) | 7 (9.1) | 2 (3.3) |
| Total | 77 (100) | 77 (100) | 61 (100) |
| Mean (SD) | 1.56 (0.93) | 1.48 (0.91) | 1.44 (0.74) |
| CFSS-DS score, mean (SD) | 30.92 (10.3) | n/a | n/a |
| Frankl scale, n (%) | |||
| 1, Definitely negative | n/a | 2 (2.6) | n/a |
| 2, Negative | n/a | 2 (2.6) | n/a |
| 3, Positive | n/a | 17 (22.08) | n/a |
| 4, Definitely positive | n/a | 56 (72.73) | n/a |
| Total | n/a | 77 (100) | n/a |
| Mean (SD) | n/a | 3.65 (0.66) | n/a |
Table 3 shows the reliability and validity of the DAQ; stability reliability and criterion validity were indicated as statistically significant. With regard to predictive validity, although the CFSS-DS correlated with the Frankl scale, the pre-tx-DAQ did not show a significant correlation with the Frankl scale. The post-tx-DAQ and follow-up-DAQ displayed significant relations with the Frankl scale.
Table 3.
DAQ Psychometric Analysis*
|
|
Correlation metrics
|
P value |
| Stability reliability | ||
| Pre-tx-DAQ and post-tx-DAQ (n = 77) | <.001 | |
| rs | 0.420 | |
| rs 2 | 0.18 | |
| Post-tx-DAQ and follow-up-DAQ (n = 61) | <.001 | |
| rs | 0.563 | |
| rs 2 | 0.32 | |
| Criterion validity | ||
| Pre-tx-DAQ and CFSS-DS (n = 74) | <.001 | |
| r | 0.584 | |
| r 2 | 0.34 | |
| Predictive validity | ||
| CFSS-DS and Frankl scale (n = 74) | .027 | |
| R | −0.257 | |
| r 2 | 0.07 | |
| Pre-tx-DAQ and Frankl scale (n = 74) | .124 | |
| rs | −0.177 | |
| rs 2 | 0.03 | |
rs, Spearman rank correlation coefficient; r, Pearson correlation coefficient.
The linear regression model analysis for the pre-tx-DAQ with ethnicity, race, age, sex, and the CFSS-DS as predictors was significant (R2 = 0.370, F[6, 67] = 6.57, P < .001). The CFSS-DS was a significant predictor for the pre-tx-DAQ after controlling for other predictors. Table 4 shows unstandardized coefficients (standard error) and standardized coefficients with P values for each predictor.
Table 4.
Linear Regression Model Analysis for Pre-tx-DAQ
|
Variable
|
Unstandardized coefficients (SE)
|
Standardized coefficients
|
P value |
| Age | 0.04 (0.04) | 0.11 | .280 |
| Sex (0: male, 1: female) | 0.10 (0.18) | 0.05 | .590 |
| Ethnicity (0: non- Hispanic or non- Latino, 1: Hispanic or Latino) | −0.12 (0.36) | −0.36 | .493 |
| Race (Reference: white) | |||
| Black or African American | −0.16 (0.25) | −0.75 | .539 |
| Other or multiple races | 0.26 (0.37) | −0.90 | .491 |
| CFSS-DS | 0.06 (0.01) | 0.60 | <.001 |
DISCUSSION
Dentists who provide oral health care to children play an important role in the prevention of dental fear. To prevent dental fear, dentists should perform a screening, which will help them prepare for the children who are at risk of becoming fearful. However, there is limited time and space to perform screenings in registration forms. Therefore, the single-item question has received attention.1 To perform an accurate measurement of dental fear, the validity and reliability of psychometric tests must be completed among the target population. Otherwise, it is not clear what is being assessed or how reliable the assessment is. Although the DAQ seems to have a high potential for measuring dental fear in children, psychometric properties of the DAQ have never been tested. Hence, the purpose of this study was to test the psychometric properties (ie, the reliability and validity) of the DAQ among the target population.
Stability Reliability: Testing Whether the DAQ Shows Children's Dental Fear Over Time
The test-retest method was used to measure the stability reliability of the single-item DAQ from 2 different time periods. One period was between pretreatment and posttreatment. While the treatment itself may have caused the patient to develop dental fear, the pre-tx-DAQ may have been affected by fear precipitated by anticipation of dental treatment as it was asked immediately prior to treatment. Thus, some participants who changed dental fear status during the first period (pre-tx-DAQ and post-tx-DAQ) were not appropriate for the stability test. Another period (post-tx-DAQ and follow-up DAQ) was set to avoid the effect of the treatment after the completion of the treatment at least 2 weeks following the initial measurement. Although the test using the second period showed only a slightly better correlation coefficient than the test using the first period did, the results showed high stability reliability on both periods.
Validity: Testing Whether the DAQ Measures Children's Dental Fear
This study used 2 other standard children's dental fear instruments, the CFSS-DS and the Frankl scale. The CFSS-DS was performed with the DAQ immediately prior to treatment to test the concurrent criterion validity by examining whether both instruments demonstrated similar results. The Frankl scale was recorded after the treatment and was used to test the predictive validity of the DAQ (ie, whether the DAQ could be used as a predictor of children's dental fear).
The CFSS-DS has been the most frequently used standard dental fear–screening questionnaire for children since 1982 in many countries. The DAQ was proven to have a high criterion concurrent validity by indicating the high correlation with the CFSS-DS. Although the CFSS-DS showed a significant correlation with the Frankl score, indicating the CFSS-DS was a good predictor of behavior, the pre-tx-DAQ did not show a significant correlation with the Frankl scale (P = .124). Low statistical power may be a possible reason for the lack of statistical significance.
As compared with the difficulty of conducting the CFSS-DS in the clinic, administering the single-item DAQ is quite feasible. However, one of the disadvantages of a single-item measure such as the DAQ is that it requires a larger sample size to see a statistical significance. In addition, the pre-tx-DAQ was highly correlated with the CFSS-DS. Thus, dentists can treat children with a high pre-tx-DAQ score differently from low-scoring children. Indeed, children's disruptive behavior during treatment can occur for multiple reasons, such as anxiety and pain, and it can change second to second. The effect of the treatment might change the fear status during the treatment. In fact, 29 (37.2%) children indicated different scores in the pre-tx- and post-tx-DAQ; the score of 11 (14.1%) children was decreased, and the score of 18 (23.1%) children was increased. The correlation between the Frankl score and post-tx-DAQ/follow-up-DAQ did show a significant correlation. Ultimately, the DAQ for children appears to be a weaker predictor for children's behavior during treatment than the CFSS-DS's predictability of their behavior.
DAQ Outcome Predictors
The regression model analysis did not reveal any significant predictors, except the CFSS-DS; therefore, no significant demographic predictor for the DAQ was found. The same demographic variables were analyzed as the predictors for the CFSS-DS, and there were no significant predictors found for the CFSS-DS either. (This statistic outcome is not presented in the Results section, because this analysis was performed only to check the important variation of demographic data for dental fear scales; it was not important data for this research's objectives.) The DAQ mainly measured children's dental fear, and their demographic factors had no significant impact on the outcome among target children who were 7 to 18 years of age.
Future Research and Limitations
The participants in this study were children (7 to 18 years of age) who were able to read the questionnaire by themselves. However, because dental professionals recommend caregivers bring their children to their first dental checkup before their first birthday,21 most children who visit the dental clinic at a young age likely cannot yet read. The usefulness of the CFSS-DS, which is filled out by parents, has also been proven for young children who cannot read. Further research should be performed regarding the parental version of the DAQ that is completed by the child's parent to examine its accuracy and deficiencies, including overrating.22,23
Finally, research assistants realized that some children could not clearly understand some phrases in the CFSS-DS, such as “people in white uniforms.” The reason may be that in modern society, particularly in the United States, many health care providers do not wear white uniforms, whereas other nondental professionals, such as cooks, do. These situations may result in children being confused by this question. Items of the CFSS-DS may benefit from further reevaluation and updating.
As the limitation of this study, the children were approached in the waiting areas of a hospital-based pediatric dental clinic in a consecutive, nonrandom manner. In addition, this research was conducted at a single site in an urban city in the Midwest region of the United States, and it may include selection bias. The pediatric dentists who saw the participants were trained to use the Frankl scale in everyday clinical practice. However, they were not calibrated for this study, resulting in potential accuracies.
CONCLUSION
Among children 7 to 18 years of age, the DAQ demonstrated stability reliability over time as well as a high concurrent criterion validity with the commonly used CFSS-DS.
ACKNOWLEDGMENTS
This study used REDCap and was supported by a grant, the Clinical and Translational Science Award (CTSC; UL1TR002548). We thank the children and pediatric dentists who provided treatment at the Irving and Jeanne Tapper Dental Center at University Hospitals Rainbow Babies & Children's Hospital. We also thank Adela Casa, Erin Sinada, James J. Rosen, and Tasha Batts who helped gather data.
APPENDIX
Pretreatment Questionnaire: CFSS-DS
The following items are situations or experiences that YOU may be afraid of.
Please circle the number matching the answer that best describes YOUR level of fear (1 = not afraid at all, 2 = a little afraid, 3 = somewhat afraid, 4 = afraid, 5 = very afraid).
|
Item
|
Subject
|
Not afraid at all
|
A little afraid
|
Somewhat afraid
|
afraid
|
Very afraid
|
| 1 | Dentist | 1 | 2 | 3 | 4 | 5 |
| 2 | Doctor | 1 | 2 | 3 | 4 | 5 |
| 3 | Injections (shots) | 1 | 2 | 3 | 4 | 5 |
| 4 | Having somebody examine your mouth | 1 | 2 | 3 | 4 | 5 |
| 5 | Having to open your mouth | 1 | 2 | 3 | 4 | 5 |
| 6 | Having a stranger touch you | 1 | 2 | 3 | 4 | 5 |
| 7 | Having somebody look at you | 1 | 2 | 3 | 4 | 5 |
| 8 | The dentist drilling | 1 | 2 | 3 | 4 | 5 |
| 9 | The sight of the dentist drilling | 1 | 2 | 3 | 4 | 5 |
| 10 | The noise of the dentist drilling | 1 | 2 | 3 | 4 | 5 |
| 11 | Having somebody put instruments in your mouth | 1 | 2 | 3 | 4 | 5 |
| 12 | Choking | 1 | 2 | 3 | 4 | 5 |
| 13 | Having to go to the hospital | 1 | 2 | 3 | 4 | 5 |
| 14 | People in white uniforms | 1 | 2 | 3 | 4 | 5 |
| 15 | Having the nurse clean your teeth | 1 | 2 | 3 | 4 | 5 |
Pretreatment and Posttreatment Questionnaires: DAQ
|
|
No
|
A little
|
Yes, quite
|
Yes, very
|
| Pretreatment | ||||
| Are you afraid of going to the dentist? | 1 | 2 | 3 | 4 |
| Posttreatment | ||||
| Are you afraid of going to the dentist? | 1 | 2 | 3 | 4 |
| Follow-up in 2 weeks (Date:____/____/______) | ||||
| Are you afraid of going to the dentist? | 1 | 2 | 3 | 4 |
Frankl's Behavioral Rating Scale
− (Definitely negative: Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme negativism.)
− (Negative: Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced [sullen, withdrawn].)
+ (Positive: Acceptance of treatment, cautious behavior at times, willingness to comply with the dentist, at times with reservation, but patient follows the dentist's directions cooperatively.)
++ (Definitely positive: Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.)
REFERENCES
- 1.McNeil DW, Randall CL. Mostofsky DI, Fortune F, editors. Dental fear and anxiety associated with oral health care: conceptual and clinical issues. Behavioral Dentistry 2nd ed. 2014. John Wiley & Sons.
- 2.Dimberg L, Lennartsson B, Bondemark L, Arnrup K. Oral health-related quality-of-life among children in Swedish dental care: the impact from malocclusions or orthodontic treatment need. Acta Odontol Scand . 2016;74(2):127–133. doi: 10.3109/00016357.2015.1059485. [DOI] [PubMed] [Google Scholar]
- 3.Boman UW, Wennstrom A, Stenman U, Hakeberg M. Oral health-related quality of life, sense of coherence and dental anxiety: an epidemiological cross-sectional study of middle-aged women. BMC Oral Health . 2012;12:14. doi: 10.1186/1472-6831-12-14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Luoto A, Lahti S, Nevanpera T, Tolvanen M, Locker D. Oral-health-related quality of life among children with and without dental fear. Int J Paediatr Dent . 2009;19(2):115–120. doi: 10.1111/j.1365-263X.2008.00943.x. [DOI] [PubMed] [Google Scholar]
- 5.McGrath C, Bedi R. Measuring the impact of oral health on quality of life in Britain using OHQoL-UK(W) J Public Health Dent . 2003;63(2):73–77. doi: 10.1111/j.1752-7325.2003.tb03478.x. [DOI] [PubMed] [Google Scholar]
- 6.Armfield JM. Predicting dental avoidance among dentally fearful Australian adults. Eur J Oral Sci . 2013;121(3 pt 2):240–246. doi: 10.1111/eos.12036. [DOI] [PubMed] [Google Scholar]
- 7.Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc . 1973;86(4):842–848. doi: 10.14219/jada.archive.1973.0165. [DOI] [PubMed] [Google Scholar]
- 8.Thomson WM, Broadbent JM, Locker D, Poulton R. Trajectories of dental anxiety in a birth cohort. Community Dent Oral Epidemiol . 2009;37(3):209–219. doi: 10.1111/j.1600-0528.2009.00473.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent . 2015;37(5):57–70. [PubMed] [Google Scholar]
- 10.Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child . 1982;49(6):432–436. [PubMed] [Google Scholar]
- 11.Arapostathis KN, Coolidge T, Emmanouil D, Kotsanos N. Reliability and validity of the Greek version of the Children's Fear Survey Schedule-Dental Subscale. Int J Paediatr Dent . 2008;18(5):374–379. doi: 10.1111/j.1365-263X.2007.00894.x. [DOI] [PubMed] [Google Scholar]
- 12.Bajric E, Kobaslija S, Juric H. Reliability and validity of Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) in children in Bosnia and Herzegovina. Bosn J Basic Med Sci . 2011;11(4):214–218. doi: 10.17305/bjbms.2011.2549. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Klingberg G. Reliability and validity of the Swedish version of the Dental Subscale of the Children's Fear Survey Schedule, CFSS-DS. Acta Odontol Scand . 1994;52(4):255–256. doi: 10.3109/00016359409029055. [DOI] [PubMed] [Google Scholar]
- 14.Nakai Y, Hirakawa T, Milgrom P, et al. The Children's Fear Survey Schedule-Dental Subscale in Japan. Community Dent Oral Epidemiol . 2005;33(3):196–204. doi: 10.1111/j.1600-0528.2005.00211.x. [DOI] [PubMed] [Google Scholar]
- 15.ten Berge M, Hoogstraten J, Veerkamp JS, Prins PJ. The Dental Subscale of the Children's Fear Survey Schedule: a factor analytic study in The Netherlands. Community Dent Oral Epidemiol . 1998;26(5):340–343. doi: 10.1111/j.1600-0528.1998.tb01970.x. [DOI] [PubMed] [Google Scholar]
- 16.Viinikangas A, Lahti S, Yuan S, et al. Evaluating a single dental anxiety question in Finnish adults. Acta Odontol Scand . 2007;65(4):236–240. doi: 10.1080/00016350701395932. [DOI] [PubMed] [Google Scholar]
- 17.Gatchel RJ. The prevalence of dental fear and avoidance: expanded adult and recent adolescent surveys. J Am Dent Assoc . 1989;118(5):591–593. doi: 10.14219/jada.archive.1989.0068. [DOI] [PubMed] [Google Scholar]
- 18.Oliveira MA, Bendo CB, Paiva SM, Vale MP, Serra-Negra JM. Determining cut-off points for the Dental Fear Survey. Sci World J . 2015;2015:983564. doi: 10.1155/2015/983564. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Neverlien PO. Assessment of a single-item dental anxiety question. Acta Odontol Scand . 1990;48(6):365–369. doi: 10.3109/00016359009029067. [DOI] [PubMed] [Google Scholar]
- 20.Armfield JM, Spencer AJ, Stewart JF. Dental fear in Australia: who's afraid of the dentist? Aust Dent J . 2006;51(1):78–85. doi: 10.1111/j.1834-7819.2006.tb00405.x. [DOI] [PubMed] [Google Scholar]
- 21.American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent . 2018;40(6):194–203. [PubMed] [Google Scholar]
- 22.Krikken JB, van Wijk AJ, ten Cate JM, Veerkamp JS. Measuring dental fear using the CFSS-DS. Do children and parents agree. Int J Paediatr Dent . 2013;23(2):94–100. doi: 10.1111/j.1365-263X.2012.01228.x. [DOI] [PubMed] [Google Scholar]
- 23.Milgrom P, Jie Z, Yang Z, Tay KM. Cross-cultural validity of a parent's version of the Dental Fear Survey Schedule for children in Chinese. Behav Res Ther . 1994;32(1):131–135. doi: 10.1016/0005-7967(94)90094-9. [DOI] [PubMed] [Google Scholar]