Received: 4 September 2022

| Revised: 22 January 2023

| Accepted: 4 February 2023

DOI: 10.1111/ipd.13058

ORIGINAL ARTICLE

Are childhood oral health behaviours and experiences

associated with dental anxiety in adolescence?

Jennifer Clow1 | Kate Northstone2 | Constance Hardwick3 | Mark Dermont4 |

Tom Dudding5

1
Dental Public Health, Defence Primary
Healthcare (Dental), HQ Defence Abstract
Medical Services Group, Lichfield, UK Background: Dental anxiety is associated with untreated dental caries.
2
Population Health Sciences, Bristol Understanding which childhood behaviours or experiences have the strongest
School of Medicine, University of
Bristol, Bristol, UK
association with later dental anxiety may help focus preventive strategies, subse-
3
National Institute for Health and Care quently limiting the burden of dental caries and anxiety.
Research ACF, Dental Core Trainee, Aim: The aim of this study was to explore whether behaviours and experiences
Bristol Dental School, University of
during childhood were associated with adolescent dental anxiety.
Bristol, Bristol, UK
4 Design: Data were obtained from the Avon Longitudinal Study of Parents and
Head of Defence Public Health Unit,
Consultant in Public Health, Defence Children (ALSPAC). Multivariable logistic regression was used to explore asso-
Public Health Unit, Headquarters ciations between adolescent dental anxiety and childhood behaviours and experi-
Defence Medical Services Group,
Lichfield, UK
ences. 1791 participants answered questions about oral health behaviours and
5
National Institute for Health and Care experiences at 8 years of age and dental anxiety questions aged 17 years.
Research ACF Restorative Dentistry, Results: Children with experience of invasive dental treatment were more likely
Honorary Lecturer, Bristol Dental
to have dental anxiety at 17 years of age than those who had not experienced
School, University of Bristol, Bristol,
UK dental treatment (OR 1.63; 95% CI: 1.12, 2.37; p = .011). Irregular dental attend-
ers in childhood had over three times the odds of dental anxiety by adolescence,
Correspondence
compared with regular attenders (OR 3.67 95% CI: 1.52, 8.88; p = .004).
Jennifer Clow, Dental Public Health,
Defence Primary Healthcare (Dental), Conclusions: Adolescent dental anxiety is associated with invasive treatment
HQ Defence Medical Services Group, and irregular dental attendance in childhood. A history of irregular attendance or
Staffordshire, Lichfield WS14 9PY, UK.
Email: [email protected]
invasive treatment may serve as a useful predictor when considering dental anxi-
ety in young adult patients. Early preventive care supports good attendance and
Funding information oral health. These actions may have secondary effects of reducing future dental
National Institute for Health and
Care Research; UK Medical Research anxiety.
Council and Wellcome Trust
KEYWORDS
adolescence, ALSPAC, behaviours, childhood, dental anxiety, experiences

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. International Journal of Paediatric Dentistry published by BSPD, IAPD and John Wiley & Sons Ltd.

Int J Paediatr Dent. 2023;00:1–10.  wileyonlinelibrary.com/journal/ipd | 1

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2    CLOW et al.

1 | I N T RO DU CT ION
Why this paper is important to paediatric
In the United Kingdom, dentally anxious individuals ex- dentists
perience more untreated dental caries, have poorer oral
health-­related quality of life1 and face barriers accessing • Regularly attending dental appointments to
care.1 Dental caries is a preventable oral health prob- experience positive noninvasive treatments for
lem affecting around half of the children in the United caries prevention may also be protective against
Kingdom,2 and dental anxiety exacerbates the burden of dental anxiety in adolescence.
caries as these individuals are less likely to attend treat- • Considering behaviours and experiences in
ment and to receive preventive care.3 Pharmaceutical and childhood, irregular dental attendance and in-
behavioural treatments for dental anxiety are resource vasive dental procedures could increase the risk
heavy.3 Strategies that can improve attendance and that of developing dental anxiety.
focus on prevention could therefore have multifaceted • Females and patients with a low socioeconomic
benefits for oral health and well-­being and could reduce status have a greater likelihood of reporting
the burden on the health system. dental anxiety.
Dental anxiety can range from feelings of unease to
great distress and terror associated with dental settings,
experiences or thoughts. Globally, 15.3% of adults and
10.0%–­29.3% of children are estimated to be dentally anx- oral health behaviours or experiences in childhood and
ious.4,5 A high prevalence of dental anxiety has been re- to assess the impact of sex and maternal education as
ported in younger adults and females.4 confounders.
Psychological theories propose that mechanisms for
developing dental anxiety may be through dentally re-
lated direct conditioning,6 for example an unpleasant or 2 | MATERIALS AND METHO D S
painful experience, or indirectly through vicarious learn-
ing, learning from others.6 An extension to these theories, Pregnant women in a geographic area in and around
however, also suggests frequent and positive experiences Bristol, with expected delivery dates from 1 April 1991
of dentistry prevent dental anxiety, despite occasional to 31 December 1992, were invited to join the Avon
painful experiences (termed latent inhibition).6,7 Longitudinal Study of Parents and Children (ALSPAC).14,15
The vicious circle of the dental fear model8 suggests 14 541 pregnancies were enrolled initially resulting in
that dental anxiety causes irregular dental attendance. 13 988 children who were alive at 1 year of age. After ap-
Bidirectional causality, however, is plausible. Therefore, proximately 7 years, further eligible families, not initially
targeting attendance patterns could be an opportunity to enrolled, were recruited and the baseline group of chil-
prevent, rather than treating, dental anxiety. dren alive at 1 year of age was 14 901. Data were collected
In adults, a clear association exists between increased in multiple ways, including self-­ completion question-
levels of dental anxiety and poorer oral health.1 This rela- naires and through face-­to-­face visits. The study website
tionship is less certain in children;9–­11 therefore, childhood contains details of data available, through a searchable
and adolescence is a key period to explore associations be- data dictionary (http://www.brist​ol.ac.uk/alspa​c/resea​
tween oral health and dental anxiety. rcher​s/our-­data/).
Dental anxiety is complex, subjective and personal with Ethics approval for the study was obtained from the
a multifactorial aetiology, which has been postulated to in- ALSPAC Ethics and Law Committee and the local re-
clude attendance pattern,9 general anxiety levels,12 socio- search ethics committees. Informed consent for the use of
economic status1 and familial influences.13 Much of this data collected via questionnaires and clinics was obtained
understanding comes from cross-­sectional studies, which from participants following the recommendations of the
are subject to recall bias.3 A prospective longitudinal de- ALSPAC Ethics and Law Committee at the time.
sign, however, provides an opportunity to strengthen ex- Dental questionnaires completed by ALSPAC chil-
isting evidence of associations between dental anxiety and dren at approximate ages of eight and 17 years pro-
specific behaviours and experiences. vided prospective data for this analysis. 16,17 From
The aim of this prospective longitudinal study was a total of 15 645 cases enrolled, 7129 completed the
to explore whether behaviours and experiences during questionnaire aged 8 years and 2644 completed a self-­
childhood were associated with dental anxiety in adoles- report dental questionnaire at approximately 17 years.
cence. Objectives were to assess whether dental anxiety Of these, 1791 had complete data available for analy-
in adolescence was associated with specific suboptimal sis (Figure 1).
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CLOW et al.    3

2.1 | Outcome variable proportion of participants with dental anxiety was calcu-
lated excluding those individuals with imputed values.
The Corah Dental Anxiety Scale (CDAS) was used to iden-
tify dental anxiety at 17 years.18 The CDAS is comprised of
four questions relating to dental scenarios. Five options 2.2 | Explanatory variables
are available for each question, ranging from feelings of no
anxiety (scoring 1) to extreme anxiety (scoring 5; Table 1). At approximately 8 years of age, dental experiences and
Total CDAS scores range from 4 to 20, the latter indicat- behaviours were collected in a postal questionnaire com-
ing the greatest possible dental anxiety.18 Total scores ≥13 pleted with parental help. Specific behaviours and expe-
indicate dental anxiety.19 riences explored in this analysis included regularity of
Dental questionnaires that included the four CDAS dental attendance, toothbrushing frequency, age of first
questions were completed, and total CDAS scores were attendance, reason for first attendance and types of dental
calculated for each participant. These scores were dichot- treatment experienced.
omised to create dentally anxious (≥13) and not dentally As regards visiting the dentist, participants who se-
anxious (<13) groups, which generated the binary out- lected ‘regularly (for check-­ups)’ were classed as regular
come variable. attenders (optimal behaviour). Those who chose ‘only for
In ALSPAC, there was an additional sixth option for toothache’, ‘not ever, really’ or ‘never’ options were classed
Questions 3 and 4. This allowed participants to state they as irregular attenders (suboptimal). This generated the bi-
had never experienced the scenario, rather than a feeling nary attendance variable. Twice-­daily toothbrushing is a
related to that scenario (Table 1 provides details). Where well-­established behaviour considered necessary to pre-
participants answered using the sixth option (not included vent oral disease.20 Participants were asked to write the
in the original CDAS questionnaire), multiple imputation number of times a day they brushed their teeth. Children
was used to impute the score for that question, rather were categorised as ‘less than twice daily’ brushers (sub-
than removing these individuals from the analysis. The optimal) if their answer was <2. Those who reported

F I G U R E 1 Flow diagram of Legend: N (number), DA (dental anxiety), CDAS (Corah Dental Anxiety Scale)
participants available for analysis.
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4    CLOW et al.

TABLE 1 Multiple-­choice questions used to generate the dental anxiety outcome variable, based on the Corah Dental Anxiety Scale.
1. If you had to go to the dentist tomorrow, how 1. I would look forward to it as a reasonable enjoyable experience
would you feel about it? 2. I wouldn't care one way or the other
3. I would be a little uneasy about it
4. I would be afraid that it would be unpleasant and painful
5. I would be very frightened of what the dentist might do
2. When you are waiting in the dentist office feel turn 1. Relaxed
in the chair how do you feel? 2. A little uneasy
3. Tense
4. Anxious
5. So anxious that sometimes I breakout in a sweat or almost feel physically sick
3. When you are in the dentist's chair waiting while 1. Relaxed
he gets the drill ready to begin working on your 2. A little uneasy
teeth, how do you feel? 3. Tense
4. Anxious
5. So anxious that sometimes I breakout in a sweat or almost feel physically sick
6. Never had treatment from the dentist treatment with a drill
4. You are in the dentist's chair to have your teeth 1. Relaxed
cleaned. While you're waiting and the dentist is 2. A little uneasy
getting out the instruments which he will use to 3. Tense
scrape your teeth around the gums, how do you 4. Anxious
feel? 5. So anxious that sometimes I breakout in a sweat or almost feel physically sick
6. Never had teeth cleaned by dentist
Note: Multiple-­choice questions are based on the Corah Dental Anxiety Scale,21 with the exception of the sixth option for Questions 3 and 4 (highlighted in
blue). Multiple imputation was used to include the 505 participants that chose Option 6 in the main analysis.

brushing twice or more were placed in the ‘twice or more by 16-­year-­olds and A-­levels were optional, more advanced
daily’ group (optimal) for the toothbrushing variable. examinations, taken at around 18 years of age.
Two binary variables of having or not having the ex-
perience of: ‘treatment awake’ and ‘treatment asleep’
were generated. Treatment awake refers to participants 2.3 | Statistical analysis
who received invasive dental treatment. This includes
those who responded yes to ever having a filling or local Analyses were undertaken using Stata/MP 17. Initially,
anaesthetic (which is required for an extraction or fill- cohort demographics were compared between the total
ing) without the use of sedation or general anaesthetics enrolled (with complete demographic data) and the total
(GA). This did not include noninvasive orthodontic or used in the main analysis and sensitivity analysis in order
preventive treatments. Treatment asleep refers to chil- to identify possible areas of bias.
dren who reported ever having GA or sedation for dental Multiple imputation was used to include 505 partici-
treatment. pants who chose the sixth option for CDAS Questions 3 or
Children were asked how old they were when they first 4. Answers to CDAS Questions 1 and 2 were used as pre-
visited the dentist. This answer was dichotomised into dictors. Multivariable normal regression using a repetitive
an optimal group (first attendance under 4 years of age) Markov chain Monte Carlo method approximated the dis-
and a suboptimal group (first attendance aged 4 years and tribution of the missing values for individuals that chose
above), to generate the ‘first attendance age’ variable. The the sixth option. The imputations occurred 10 times, and
variable ‘reason for first attendance’ at the dentist was cre- estimation commands were run which adjusted the coef-
ated using three categories: for a ‘check-­up’, ‘with parents’ ficients and standard errors for the variability between the
or ‘for toothache’. The latter was considered as the subop- imputations during analysis. This maximised the sample
timal category. size available for the main analysis (N = 1791).
The co-­variants of sex and maternal education were Logistic regression was used to calculate unadjusted
also collected. Highest level of maternal education was and adjusted (controlling for sex and maternal education)
collected during pregnancy and categorised as high (de- odds ratios (ORs), 95% confidence intervals (CI) and p-­
gree or A-­ level), medium (O-­ level) or low (Certificate values for dental anxiety. Participants were similar in age
of Secondary Education or vocational). In the United at both of the data collection points, so age was not ad-
Kingdom, O-­levels were the statutory examinations taken justed for. Mean ages of completion were 7.68 (standard
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CLOW et al.    5

deviation [SD] 0.21) and 17.21 (SD 0.36) years for the ex- experience of treatment awake by the age of eight had
posure and outcome variables, respectively. almost twice the odds of dental anxiety in adolescence
Participants with complete CDAS data (N = 1286) were compared with children without experience of treatment
included in sensitivity analyses to assess the impact of awake (OR: 1.70; 95% CI: 1.18, 2.45; p = .004). These
using multiple imputation. odds attenuated minimally (OR: 1.63; 95% CI: 1.12, 2.37;
p = .01) after adjusting for sex and maternal education.
All further ORs reported are adjusted for sex and mater-
3 | R E S U LTS nal education. A greater association with dental anxiety
was seen for participants who had experienced treatment
The demographic characteristics of the 1791 participants asleep in childhood, compared with those that had not
in the complete analysis differed from those originally (OR: 3.14; 95% CI: 1.96, 5.04; p < .001; Table 3).
enrolled. Table 2 shows almost two-­thirds of those in the
analysis were female and over half had a high maternal
education. This contrasts with the roughly even split be- 3.2 | Attendance behaviour
tween sexes and across the three maternal education cat-
egories at enrolment. Irregular attenders were over three times more likely to
There was a greater proportion of reported dental anx- have dental anxiety in adolescence compared with those
iety in females and those with low maternal education. who attended regularly as children (OR: 3.67; 95% CI:
Logistic regression (Table 3) showed strong evidence that 1.52, 8.88; p = .004).
males were much less likely to report dental anxiety com-
pared with females (OR 0.21; 95% CI: 0.13, 0.36; p < .001).
Teenagers with low maternal education were almost three 3.3 | Other variables
times more likely to have dental anxiety than those with
a high maternal education (OR 2.61; 95% CI: 1.66, 4.10; Less than twice-­daily toothbrushing and first attending
p = .002). As the outcome used in this study is relatively with parents showed no evidence of an association with
rare, the ORs presented in our results approximate the risk dental anxiety (OR: 0.96; 95% CI: 0.59, 1.56; p = .873
(prevalence) ratio. and OR: 1.02; 95% CI: 0.71, 1.48; p = .273, respectively;
Table 3).

3.1 | Treatment experience

3.4 | Sensitivity analysis
Of those in the treatment awake group, most (89.2%,
N = 479) experienced fillings and the remainder (N = 58) 7.4% of adolescents, with complete CDAS data (N = 1286),
experienced a filling, extraction or both. Participants with were classified as dentally anxious (Table 2). Females

TABLE 2 Demographic characteristics at enrolment and analysis.

Main Complete CDAS data for sensitivity Incomplete

Enrolment Analysis analysis CDAS data
Not
Dentally dentally
N = 12 461 N = 1791 N = 1286 anxious anxious p-­value N = 505
Sex N % N % N % N % N % <.001 N %
Female 6027 48.4 1096 61.2 771 59.9 82 10.6 689 89.4 325 64.4
Male 6434 51.6 695 38.8 515 40.1 13 2.5 502 97.5 180 35.6
Maternal <.0019
education
High 4397 35.3 938 52.4 676 52.6 39 5.8 637 94.2 262 51.9
Medium 4317 34.6 587 32.7 419 32.6 31 7.4 388 92.6 168 33.3
Low 3747 30.1 266 14.9 191 14.8 25 13.1 166 86.9 75 14.8
Total 12 461 1791 1286 95 7.4 1191 92.6 505
Abbreviations: CDAS, Corah Dental Anxiety Scale; Incomplete CDAS data, Multiple imputation used to include in main analysis; N, Number.
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6    CLOW et al.

TABLE 3 Association between dental anxiety and explanatory variables.

Unadjusted Adjusted
Explanatory
variable N OR 95% CI p-­value OR 95% CI p-­value
Sex <.001
Female 1096 1
Male 695 0.21 0.13, 0.36
Maternal education .002
High 938 1
Medium 587 1.37 0.91, 2.08
Low 266 2.61 1.66, 4.10
Attendance .004 .004
Regular 1758 1 1
Irregular 33 3.45 1.47, 8.12 3.67 1.52, 8.88
Daily toothbrushing .845 .873
≥twice 1478 1 1
<twice 313 0.95 0.59, 1.53 0.96 0.59,1.56
First attendance age .068 .095
Under 4 1556 1 1
4 and older 235 1.55 0.97, 2.49 1.51 0.93,2.46
First attendance reason .352 .273
Check-­up 943 1 1
With parent 839 0.93 0.65, 1.34 1.02 0.71, 1.48
Toothache 9 3.46 0.70, 16.95 3.95 0.73, 21.32
Ever had dental treatment while awake .004 .011
No Tx awake 1254 1 1
Tx awake 537 1.70 1.18, 2.45 1.63 1.12, 2.37
Ever had dental treatment while asleep <.001 <.001
No Tx asleep 1636 1 1
Tx asleep 155 3.32 2.11, 5.22 3.14 1.96,5.04
Abbreviations: 95% CI, Confidence interval; Adjusted, For sex and maternal education; N, Number; OR, Odds ratio; Tx, Treatment.

and those with a low maternal education reported the The requirement for dental GA (or sedation) in child-
greatest proportions of dental anxiety, 10.6% and 13.1%, hood is predominantly for the extraction of carious
respectively. Sensitivity analysis (N = 1286) suggested teeth.21 Therefore, experience of treatment asleep could
that results were similar for all variables, except dental indicate experience of tooth extraction. An observational
attendance (Table 4). Compared with the main analysis, study13 found an association between tooth extraction and
the attendance variable effect size was smaller, the 95% dental anxiety, with a similar OR (3.5) to the association
CI crossed the null and p-­value indicated weak evidence found here between treatment asleep and dental anxiety.
(OR: 2.72; 95% CI: 0.85, 8.76; p = .093). Directional causality for dental anxiety, however, cannot
be assumed since dental anxiety could be a key reason for
providing treatment under GA. Many factors including
4 | DI S C USSION clinical necessity, parental preferences and levels of coop-
eration (not necessarily dental anxiety) may have contrib-
We found that experience of invasive dental treatment uted to the treatment asleep intervention.
under sedation or GA (treatment asleep) was associated An association was also seen between dental anxiety
with around three times greater likelihood of dental anxi- and treatment asleep. Restorations (fillings) are a com-
ety in adolescence in a UK cohort of children. mon type of invasive dental treatment for children,22 and
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CLOW et al.    7

T A B L E 4 Impact of sensitivity testing on explanatory variables

attendance) and potential misclassification bias, which
of interest and their association with dental anxiety.
are discussed below.
Adjusted sensitivity analysis (N =1286) Attrition in the cohort may have influenced the re-
Explanatory
sults due to altered demographic proportions. Females
variable N OR 95% CI p-­value were over-­represented with a 20% increase in enrolment.
Participants with a low maternal education were under-­
Attendance
represented by half since enrolment (Table 2). This attri-
Regular 1264 1
tion is important because the true proportion of dental
Irregular 22 2.72 0.85, 8.76 .093 anxiety in those with low maternal education was likely to
Ever had dental treatment while awake be under-­represented. It is possible that severely dentally
No Tx awake 835 1 anxious individuals failed to complete the dental ques-
Tx awake 451 1.61 1.05, 2.48 .029 tions, resulting in further bias, towards the null, thereby
Ever had dental treatment while asleep diluting the association of relevant behaviours and expe-
No Tx asleep 1167 1 riences with dental anxiety. The UK-­wide prevalence24 of
dental anxiety in 15-­year-­olds has been reported as 10%
Tx asleep 119 2.95 1.71, 5.10 <.001
which is higher than the 7.4% in this study, suggesting an
Abbreviations: 95% CI, 95% confidence interval; N, Number; OR, Odds ratio;
element of under-­representation.
Tx, Treatment.
The inferences that could be drawn from some ex-
planatory variables were limited due to a lack of power.
89.2% (N = 479) of the treatment awake group experi- For example, there was weak evidence of any association
enced fillings. This study, however, showed that the asso- between dental anxiety and those who first attended for
ciation between dental anxiety and treatment asleep was toothache, with only a small number of participants re-
much stronger than the association with treatment awake, porting that they first attended for toothache (N = 9).
suggesting that childhood experience of extractions plays There was an attenuation in the association between at-
a bigger role than experience of fillings. This idea is sup- tendance and dental anxiety in the sensitivity analysis.
ported by other studies.13,23 This is also likely to have been driven by a reduction in
This research and other studies have shown dental power.
anxiety to be associated with treatment asleep, treatment The multivariable logistic regression was limited to
awake, tooth extraction23 or a bad dental experience.21 confounders of sex and maternal education. This avoided
An unpleasant dental experience could be considered an using explanatory variables incorrectly as confounders,
overarching description for these three explanatory vari- when these variables were acting as effect modifiers.
ables. Future work could focus on unpleasant dental expe- Despite successful validation,19 the CDAS has short-
riences, rather than specific treatment types, to assess the comings that may have led to misclassification bias. Some
strength of association. clinicians argue that due to the order and phrasing of
Children reporting irregular dental attendance were multiple-­choice questions, moderately dentally anxious
more likely to be dentally anxious teenagers. This finding individuals are not accurately identified and only highly
agrees with existing observational studies, reporting that anxious or very relaxed patients can be categorised ac-
dental anxiety and irregular dental attendance are associ- curately.25 Furthermore, CDAS does not include any
ated9,13 and fits with the mechanism of latent inhibition questions related to local anaesthetic, which is a specific
described by psychological theory.6 For example, regular contributor to dental anxiety for some patients.25 Recall
attendance for check-­ups or simple noninvasive preventive bias may have been present because the questionnaires
treatments (such as fluoride varnish application) provide asked the 8-­year-­olds and their parents to recall experi-
an opportunity to build positive nonpainful experiences. ences that may have happened several years earlier. The
This cohort showed a greater prevalence of dental anx- dental experience questions though not formally validated
iety in females and those with low maternal education. in the ALSPAC questionnaire have been used in other
Despite the strong association between dental anxiety and studies, and when testing for sensitivity and specificity, a
these demographic variables, their confounding effect on small risk of misclassification was found.26
attendance behaviour or treatment experience association Longitudinal studies can offer an opportunity to ex-
was minimal. This highlights the importance of atten- plore causality; as dental anxiety, however, was only mea-
dance and treatment experience as explanatory variables, sured at 17 years of age, it is not possible to confirm the
irrespective of demographics. temporality of relationships observed. It is possible that
Limitations of this study include cohort attrition, an individual developed dental anxiety after or during
lack of power for an explanatory variable (reason for episodes of dental treatment during childhood or that it
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8    CLOW et al.

occurred after a period of irregular attendance but it is receive preventive focussed care remains important. It
equally feasible that it pre-­dated these experiences. could also yield benefits in terms of reducing the risk of
This study contributes to evidence that irregular dental subsequent dental anxiety with all the individual impacts
attendance and experience of invasive treatment in child- and treatment resource implications this entails.
hood are associated with a greater likelihood of dental
anxiety in adolescence and these associations remained AUTHOR CONTRIBUTIONS
following adjustment for demographic variables. Other J. C. and T. D. conceived the ideas; M. D., T. D., and K. N
oral health behaviours and experiences, such as twice-­ developed ideas and the analysis plan; J. C. and C. H ana-
daily toothbrushing or first attending the dentist for a lysed the data; J. C. led the writing; all authors edited and
check-­up or with parents, appear to have no association reviewed the final document.
with dental anxiety.
It is well established that childhood caries and subse- ACKNO​WLE​DGE​MENTS
quently dental treatment is a predictor for caries later in We are extremely grateful to all the families who took
life.27 This study indicates that irregular attendance and part in this study, the midwives for their help in recruit-
dental treatment due to childhood caries may also be pre- ing them and the whole ALSPAC team, which includes
dictors of increased risk of dental anxiety by adolescence. interviewers, computer and laboratory technicians, cleri-
Although the association with attendance should be cal workers, research scientists, volunteers, managers, re-
treated with caution due to the sensitivity analysis, exist- ceptionists and nurses. The UK Medical Research Council
ing studies support this finding across several contexts.3,28 and Wellcome Trust (Grant ref. 217065/Z/19/Z) and the
The complex interplay of several potential co-­factors in University of Bristol provided core support for ALSPAC.
inducing dental anxiety should be considered as part of This publication is the work of the authors who serve as
future work aimed at generating hypotheses for testing. guarantors for the contents of this paper. M. Dermont and
Work to develop a directed acyclic graph29 would be use- J. Clow are HM Forces Officers who have no commercial
ful to help identify and explore the relationship between interests and have received no payment for conducting
more factors. This would enable the correct inclusion of this work. T. Dudding and C. Hardwick received sup-
potential confounders and exclusion of effect modifiers port from the UK National Institute for Health Research
and colliders in a more complex multivariable logistic re- Academic Clinical Fellowship scheme.
gression based on larger sample sizes.
Childhood experience of dental care, including atten- CONFLICT OF INTEREST STATEMENT
dance patterns and the need for treatment, is associated The authors declare no conflict of interest.
with adolescent levels of dental anxiety. Besides consid-
ering a child's past experiences, sex and socioeconomic DATA AVAILABILITY STATEMENT
status, clinicians should also consider their influence on a The data that support the findings of this study are availa-
young patient's feelings towards the dentist and how this ble on request from the corresponding author. The data are
may impact future morbidity and access to dental care. not publicly available due to privacy or ethical restrictions.
Where possible, positive treatment experiences should be
provided; this, however, must be balanced with the clini- ORCID
cal need for more invasive treatment to avoid the negative Jennifer Clow https://orcid.org/0000-0002-9227-1689
impacts of dental pain and infection and emphasises the Kate Northstone https://orcid.org/0000-0002-0602-1983
need for early dental education. Constance Hardwick https://orcid.
org/0000-0002-2869-1320
Tom Dudding https://orcid.org/0000-0003-3756-040X
5 | CO N C LUSION
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