The relationship between temperament and dental fear and anxiety: a systematic review

www.nature.com/ebd ARTICLE The relationship between temperament and dental fear and anxiety: a systematic review ✉ Ana Clara Ferreira Paiva 1 , Daniela Rabelo-Costa1, Izabella Barbosa Fernandes1, Marcela Baraúna Magno2, Lucianne Cople Maia2, 1 Saul Martins Paiva and Cristiane Baccin Bendo1 © The Author(s), under exclusive licence to British Dental Association 2023 KEY POINTS ● ● 1234567890();,: ● Dental fear and anxiety (DFA) can negatively impact the oral health of children and adolescents and also can be a very challenging factor for the dentist to offer the best approach to oral health care. It reinforces the importance of administer a more appropriate management approach and give positive experiences to the pediatric patient and family to reduce DFA. Children and adolescents with a tendency towards emotionality and shyness are at higher risk of having DFA. Very low certainty of evidence about the relationship between DFA and temperament demonstrate the importance of using standardized and reliable instruments in future studies. OBJECTIVE: To investigate the relationship between temperament traits and dental fear and anxiety (DFA) in children and adolescents by the means of a systematic review (PROSPERO #CRD42020207578). METHODS: The PEO (Population, Exposure, and Outcome) strategy was followed using children and adolescents as the population, temperament as the exposure, and DFA as the outcome. A systematic search for observational studies (cross-sectional, case-control, and cohort) without restrictions on year or language of publication was performed in seven databases (PubMed, Web of Science, Scopus, Lilacs, Embase, Cochrane, and PsycINFO) in September 2021. Grey literature search was performed in OpenGrey, Google Scholar, and in the reference list of included studies. Study selection, data extraction, and risk of bias assessment were carried out independently by two reviewers. The Fowkes and Fulton Critical Assessment Guideline was used to assess methodological quality of each study included. The GRADE approach was performed to determine the certainty of evidence of relationship between temperament traits. RESULTS: This study recovered 1362 articles, of which 12 were included. Despite the high heterogeneity of methodological aspects, qualitative synthesis by subgroups showed a positive association/correlation between emotionality, neuroticism, and shyness with DFA in children and adolescents. Different subgroups analysis showed similar results. Eight studies were classified as having low methodological quality. CONCLUSION: The main shortcoming of the included studies is the high risk of bias and a very low certainty of evidence. Within its limitations, children and adolescents with a temperament-like emotionality/neuroticism and shyness are more likely to present higher DFA. Evidence-Based Dentistry (2023) 24; https://doi.org/10.1038/s41432-023-00852-0 INTRODUCTION Fear and anxiety are normal reactions in response to some form of potential or real threat, and can promote biological body changes that are important to one’s survival1. Fear results from a concrete situation, and anxiety is related to the anticipation of a possible threat2. In the dental environment, fear can be characterized as an emotional reaction to specific stimuli, such as a drilling sound or the smell of a dental material, which is called dental fear (DF). Dental anxiety (DA) is a state of apprehension resulting from the anticipation of some thoughts about the dental appointment. The related reactions are different. Fear is more associated with excitability for fight or flight, and anxiety is more an apprehension state looking for a future situation, but these can sometimes overlap2. However, it is hard to differentiate between fear and anxiety in dentistry; consequently, the term “dental fear and anxiety” (DFA) is used to refer to strong negative feelings associated with dental treatments or dental environments3,4. A systematic review demonstrated a pooled prevalence of DFA of 23.9% in children and adolescents between 3 and 18 years of age5. DFA is common in child development and can occur by endogenous or exogenous factors6. The exogenous factors related 1 Department of Pediatric Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil. 2Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil. ✉email: Received: 26 February 2022 Accepted: 16 June 2022 Published online: 3 March 2023 2 to higher DFA involve dental pain and negative dental experiences7,8, as well as a DFA that is inherited from the children’s parents9. Endogenous factors for DFA are related to individuals’ characteristics, such as age, sex, general anxiety, depression and temperament, or personality traits2,10,11. Temperament or personality traits can be used as synonymous terms to define individuals’ differences in emotional responses to the environment12,13. These traits are present in early infancy and are relatively stable throughout life. Temperament can also be defined as a characteristic which is part of personality, and temperament as an early stage of personality development12,13. These theories have been studied for years and actually remains as a theoretical challenge due its differences,13. These differences impact specially on the number of dimensions and instruments to measure these constructs12–15. Although these particularities, some of the dimensions have similar definitions and can be grouped even if they are from different scales12–15. The most widely theories of temperament used in dental research include the constructs of emotionality, activity, shyness, sociability, impulsivity, neuroticism, extroversion, and non-sincerity dimensions12,14,15. Some of these dimensions are in concordance with the concepts by the Big Five Personality Traits13, a theory which has a spread use in personality studies but not on studies about DFA. During dental care, a child is under the influence of various and often unknown stimuli, which can be recognized by them as threats. The way children react emotionally in different situations can be an indication of how they would react in situations like dental care. The literature demonstrates a possible association between temperament-like emotionality/neuroticism and DFA16–18. By contrast, some studies have not demonstrated such an association19,20. However, to date, no systematic review of the literature on this topic has been conducted to provide a synthesis of the primary studies, which would provide a greater basis for the relationship between temperament and DFA in children and adolescents. The results of the present study may support pediatric dentists in their daily practice, and may also be a way to guide new research on the topic in an attempt to understand how temperament could be associated/correlated with DFA in children and adolescents. (...truncated)