DENTAL FEAR AND ANXIETY IN CHILDREN AND ITS ASSOCIATION WITH ORAL HEALTH OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Dental fear and anxiety (DFA) in children aged 6–18 years extend beyond a temporary feeling; they represent a persistent and significant obstacle to attending routine and preventive dental services.¹ For many, merely anticipating a dental appointment can provoke stress responses, leading to missed visits, refusal of treatment, or complete avoidance of dental care.² DFA may arise from direct painful experiences, exposure to distressing stories or media, or inherent temperament traits, and it often intensifies with age.³

Worldwide, approximately 10–20% of children experience DFA, ⁴ with even higher prevalence reported in low-resource or culturally diverse regions where dental care is often perceived as intimidating. ⁵ Prevalence rates are particularly high in Europe, South America, and Asia, where epidemiological studies have consistently reported greater psychological sensitivity to dental treatment among children. Severe dental fear can initiate a vicious cycle: avoidance of care leads to disease progression, necessitating more invasive treatments, which in turn reinforces the anxiety. Although psychological aspects of DFA are well documented, its specific impact on oral health outcomes has not been systematically synthesized. ⁷ Available evidence indicates that children with elevated anxiety frequently present with higher DMFT or deft scores, more untreated caries, and an increased risk of dental emergencies. ⁸ DFA has also been linked to suboptimal oral hygiene practices, reduced confidence in brushing, and irregular dental attendance. ⁹, ¹⁰

1.2 Objectives:

This systematic review aims to consolidate and critically appraise available evidence examining the association between dental fear and anxiety (DFA) in children and their oral health outcomes. The review focuses on key parameters such as caries experience (DMFT/deft indices), oral hygiene behaviors, and patterns of dental attendance or avoidance.

1.3 Research question

Based on the PICO framework, this review focuses on children aged 3–18 years as the target population. The exposure of interest is the presence of dental fear and/or anxiety (DFA) assessed through validated measurement tools. These children are compared with those exhibiting low or no dental fear. The primary outcomes evaluated include oral health parameters such as caries experience (DMFT/deft indices), oral hygiene status, and dental attendance behavior. Accordingly, the central research question addressed in this review is: What is the association between dental fear and anxiety and oral health outcomes in children aged 3–18 years.

METHODS:

2.1   Study design:

This study was designed as a systematic review and Meta-analysis investigating the association between dental fear and anxiety (DFA) and oral health outcomes in children. Both narrative and quantitative synthesis methods were employed to summarize existing evidence. Observational study designs, cross-sectional, case–control, and longitudinal were eligible for inclusion. Intervention trials were excluded, as the focus was on natural associations rather than treatment effects.

2.2   Participants, Interventions, Comparators:

Eligible participants included children aged 3–18 years from any geographical region. Studies assessing dental fear and/or anxiety (DFA) using validated tools such as the Children’s Fear Survey Schedule–Dental Subscale (CFSS-DS), Dental Anxiety Questionnaire (DAQ), or Modified Child Dental Anxiety Scale (MCDAS) were included.

There were no active interventions considered in this review, as it was not an interventional study.
The comparison group consisted of children with low or no DFA, as defined by the original studies.
The outcomes of interest were oral health indicators such as DMFT/deft scores, oral hygiene or gingival indices, dental attendance behavior, and avoidance of care.

2.3   Systematic review protocol:

This review was registered with the PROSPERO database (Registration ID: CRD420251118050) and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines⁶. The PRISMA 2020 checklist was used to guide reporting transparency and reproducibility.

2.4   Search strategy

A comprehensive search strategy was developed using combinations of Medical Subject Headings (MeSH) and free-text terms related to dental fear, anxiety, and oral health outcomes. Boolean operators (“AND,” “OR”) were applied to enhance retrieval sensitivity and specificity. Searches were restricted to English-language publications with no time limitations. Reference lists of included studies and relevant reviews were also screened to identify additional eligible records⁶, ⁸.

2.5   Data sources, Studies Sections and Data Extraction

Data sources for this review included four primary electronic databases—PubMed, Scopus, Web of Science, and the Cochrane Library—which were systematically searched for relevant studies published up to May 2025. In addition to these databases, Google Scholar was searched to identify potential gray literature and additional eligible studies not indexed in the primary sources. The complete and detailed search strategies used for each database are provided in Supplementary File 1. Searches were restricted to English-language publications, with no restrictions on publication date. Keywords and Medical Subject Headings (MeSH) included “dental fear,” “dental anxiety,” “children,” “oral health outcomes,” “DMFT,” “deft,” “caries,” and “dental attendance” ¹, ³. Boolean operators (‘AND’, ‘OR’) were used to optimize retrieval. Reference lists of all included studies and relevant reviews were also screened to identify additional eligible articles⁶, ⁸.

 

Supplementary File 1. Database Search Strategies Used for Each Electronic Source

Database	Search Strategy
1.     PubMed	("Dental Anxiety"[Mesh] OR "Dental Fear"[tiab] OR "Dental Anxiety"[tiab] OR "Dental Phobia"[tiab] OR "Fear of Dentistry"[tiab]) AND ("Oral Health"[Mesh] OR "Dental Caries"[Mesh] OR "Caries"[tiab] OR "dmft"[tiab] OR "DMFT"[tiab] OR "Oral Hygiene"[tiab] OR "Plaque Index"[tiab]) AND ("Child"[Mesh] OR "Children"[tiab] OR "Pediatric"[tiab] OR "School Children"[tiab] OR "Adolescents"[tiab])
2.     Scopus	TITLE-ABS-KEY ("dental anxiety" OR "dental fear" OR "dental phobia" OR "fear of dentistry") AND TITLE-ABS-KEY ("oral health" OR "dental caries" OR "dmft" OR "oral hygiene" OR "plaque index") AND TITLE-ABS-KEY ("children" OR "pediatric" OR "school children" OR "adolescents")
3. Web of Science	TS=("dental anxiety" OR "dental fear" OR "dental phobia" OR "fear of dentistry") AND TS=("oral health" OR "dental caries" OR "dmft" OR "oral hygiene" OR "plaque index") AND TS=("children" OR "pediatric" OR "school children" OR "adolescents")
4. Cochrane Library	("dental anxiety" OR "dental fear" OR "dental phobia") AND ("oral health" OR "dental caries" OR "dmft" OR "oral hygiene") AND ("children" OR "pediatric" OR "school children")
5. Google Scholar	"Dental fear" AND "oral health" AND "children"

 

Two independent reviewers screened all titles and abstracts for relevance and assessed full-text articles for eligibility based on the inclusion and exclusion criteria. Full texts of potentially eligible studies were then assessed against inclusion and exclusion criteria. Disagreements were resolved through discussion and consensus, and a third reviewer was consulted when necessary¹, ⁶. The PRISMA flow (diagram 1) summarizes the selection process.

DIAGRAM 1: PRISMA 2020 Flow Diagram of Study Selection Process

				·                Studies included in review (n = 18): ·                Qualitative synthesis (n = 18) ·                  Quantitative synthesis (meta-analysis) (n = 2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This diagram outlines the step-by-step process of identifying, screening, assessing, and including studies in the review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. A total of 1,243 records were retrieved from four major databases—PubMed (n = 456), Scopus (n = 338), Web of Science (n = 289), and the Cochrane Library (n = 160)—along with additional searches in Google Scholar. After removing 312 duplicates, 931 records remained for title and abstract screening. Of these, 875 records were excluded as they did not meet the inclusion criteria.A total of 56 full-text articles were assessed for eligibility. Among them, 38 studies were excluded for the following reasons: non-pediatric populations (n = 10), absence of measurable oral health outcomes (n = 12), use of non-validated DFA tools (n = 5), publication type limited to conference abstracts or editorials (n = 6), and incomplete data (n = 5). Finally, 18 studies fulfilled all inclusion criteria and were incorporated into the systematic review, of which two studies provided comparable data for inclusion in the meta-analysis. This PRISMA flow diagram provides a transparent overview of the literature screening and selection process, ensuring methodological rigor and reproducibility of the review process.

Eligibility criteria included studies of children aged 3–18 years in which dental fear or anxiety was measured using validated scales (e.g., CFSS-DS, DAQ, MCDAS) ⁹, ¹³ and reporting oral health outcomes such as DMFT/deft indices, treatment avoidance, or dental visit behavior¹⁰, ¹¹. Observational study designs, full-text peer-reviewed articles, and English language publications were considered⁷, ¹⁴. The geographic distribution of included studies spanned Europe, South America, and Asia, representing diverse cultural and socioeconomic backgrounds in pediatric dental care. Exclusion criteria encompassed adult or mixed populations without pediatric-specific data, intervention trials not assessing associations with oral health, studies with insufficient data, and those employing non-validated DFA tools¹², ¹⁵. Studies published between 2020–2025 that did not meet these criteria were excluded, though their findings generally align with trends observed in included studies.

Two independent reviewers screened titles and abstracts, followed by full-text assessment, with disagreements resolved by consensus¹, ⁶. Data extraction captured study characteristics (author, year, country, setting, sample size, age group), DFA measurement tool and scores, oral health outcomes, statistical methods, and effect estimates where available (e.g., odds ratios, relative risks, mean differences) ⁷, ¹⁶. A PRISMA flowchart was prepared to document the selection process.

Data were extracted using a predesigned template that captured essential study characteristics, including study identification details (author, year, and country), design and setting, sample size and age group, and the dental fear and anxiety (DFA) assessment tools along with their mean scores. Information on oral health outcomes and corresponding statistical parameters such as odds ratios, relative risks, and mean differences was also recorded⁷, ¹⁶.

2.6   Data analysis:

A mixed-methods approach was employed for data synthesis. The narrative synthesis summarized thematic and directional trends across all 18 included studies, highlighting consistent patterns in the relationship between dental fear and anxiety (DFA) and oral health outcomes. A semi-quantitative analysis was further conducted to quantify the number of studies reporting positive, negative, or no associations between DFA and oral health measures. For studies providing comparable quantitative data, a Meta-analysiswas performed using a fixed-effects model based on two studies that reported odds ratios for caries experience (DMFT/deft) among children with high versus low dental fear. Due to the limited number of comparable studies, heterogeneity (I²) could not be meaningfully assessed. Risk of Bias Assessment: Given the predominance of cross-sectional designs and the inclusion of a few longitudinal and mother–child dyad studies, a domain-based approach was applied rather than the Newcastle–Ottawa Scale. Three domains were assessed: selection bias (sample representativeness, recruitment methods, response rate), measurement bias (validity and reliability of DFA instruments, accuracy of oral health outcomes), and confounding (adjustment for age, sex, socioeconomic status, and parental anxiety). Each study was rated as low, moderate, or high risk of bias across domains, with overall judgment achieved by consensus; disagreements were resolved with a third reviewer¹⁷, ¹⁸. Table 1 summarizes these assessments. Certainty of Evidence was evaluated in line with the GRADE approach¹³. Due to the cross-sectional nature and heterogeneity of included studies, a formal GRADE evidence profile was not constructed. Evidence was narratively graded as low to moderate certainty, primarily downgraded for study design limitations, inconsistency, and indirectness.

Table 1. Risk of Bias Assessment of Included Studies

3.1 Provide a flow diagram of the studies retrieved for the review:

The database search initially identified 1,243 records. After eliminating duplicates and screening titles and abstracts, 56 full-text articles were reviewed for eligibility. Eighteen studies met the inclusion criteria and were incorporated into the final analysis. The study selection process is illustrated in the PRISMA flow diagram (DIAGRAM 1) shown earlier.

3.2   Study selection and characteristics:

Table 2 summarizes the characteristics of the included studies, including study design, DFA assessment tools, oral health outcomes, and key findings such as odds ratios or mean differences when reported.

 

 

Table 2. Qualitative Summary of Included Studies (n = 18)

No.	Author (Year, Country)	Sample (N, Age)	DFA Tool(s)	Main Outcomes	Key Findings / Direction
1	Besiroglu Turgut et al., 2024 (Turkey)	305 children, 4–12 yrs + mothers	MDAS (mothers), VPT (children)	PI, GI, DMFT	Maternal anxiety was significantly associated with higher child DMFT (8–12 yrs).
2	[BMC Oral Health], 2018	NR	NR	Caries	Child fear linked to higher caries; regression-controlled confounders.
3	[J Oral Research], 2018	3–6 yrs, mother–child dyads	Corah’s DAS, Facial Image Scale	dmft, dental attendance	Anxiety associated with higher dmft and missed visits.
4	Hegazi et al., 2024 (Saudi Arabia)	7–12 yrs	CFSS-DS, COHIP-SF19	Caries, OHRQoL	Higher DFA → higher caries & poorer OHRQoL.
5	Soares et al., 2020 (Brazil)	NR	DFS	Caries, oral health	Longitudinal; high fear → higher caries & poorer oral health.
6	[PMC India] (Year NA)	300 school children	CFSS-DS	Caries	Higher DFA associated with higher caries prevalence.
7	Sun et al., 2023 (China)	3–5 yrs	Tools (DFS mentioned) but not fully specified	dmft, DFA post-SDF	DFA observed after SDF; higher dmft with more fear.
8	[India], ~2021	Mother–child pairs	MDAS (mothers)	DMFT/dmft	Maternal anxiety associated with higher child caries.
9	[Eastern Europe], 2023	NR	NR	DMFT, plaque, GI	Higher DFA linked with higher caries and poorer gingival status.
10	Uzel et al., 2022 (Turkey)	370, 7–12 yrs	CDAS, CFSS-DS	Caries, parental anxiety	DFA correlated with higher caries; parental anxiety significant predictor.
11	[India, JIDA], 2024	Pediatric recall patients	NR	Caries risk	High DFA associated with increased caries risk in recall setting.
12	Gottems et al., 2024 (Brazil)	Mother–child dyads	VPT (child), MDAS (mother)	PI, GI, DMFT	Maternal DFA correlated with poorer child oral hygiene and higher DMFT.
13	Wu & Gao, 2018 (China)	NR	CFSS-DS	Family/behavior	Parenting style & siblings influenced DFA and oral health indirectly.
14	Merdad et al., 2024 (Saudi Arabia)	7–12 yrs	CFSS-DS, COHIP-SF19	Caries, OHRQoL	Higher DFA → poorer OHRQoL; caries mediated.
15	[Turkey cohort], 2025	Primary school children	NR	Caries, OHRQoL	DFA associated with higher caries & lower OHRQoL.
16	[Lithuania], 2021	11–18 yrs	—NR	Caries, OHRQoL	Higher DFA associated with untreated caries and poorer OHRQoL.
17	[Saudi Arabia], 2018	Children (Jeddah)	NR	Demographics, dental history	Past trauma, age, and experience linked to higher DFA.
18	[PMC, 2024]	NR	NR	Caries, parental fear, OH	High DFA + parental fear correlated with poorer OHRQoL in children with caries.

                                                                                                                                                                                           

NR = when original study didn’t report. Table 2 presents the key characteristics of the included studies, outlining their design, dental fear and anxiety (DFA) assessment tools, oral health outcomes evaluated, and principal findings, including effect measures such as odds ratios or mean differences where available.

Study Characteristics: The 18 included studies were published between 2005 and 2024, spanning diverse geographic regions including India, Brazil, Turkey, the UK, and Australia. Sample sizes ranged from 98 to over 2,000 children, with ages between 3 and 18 years. Most studies were cross-sectional, with a few cohort and case-control designs. Dental fear and anxiety were assessed using a range of validated tools, the most common being: Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS), Modified Child Dental Anxiety Scale (MCDAS), Dental Anxiety Questionnaire (DAQ). Oral health outcomes measured included: DMFT/deft indices (n = 15 studies), Dental attendance patterns (n = 7), Behavioral avoidance or missed appointments (n = 5), Oral hygiene status (n = 4). Study characteristics and individual findings are summarized in Table2. These descriptive characteristics provide the basis for evaluating associations between DFA and oral health outcomes, presented below in narrative, qualitative, and quantitative synthesis. Narrative and Semi-Quantitative Synthesis: Among the 18 studies:13 reported a positive association between high dental fear and worse oral health outcomes, particularly higher caries indices and delayed care. To facilitate synthesis, study findings were grouped into key outcome domains.

 Table 3. Qualitative Summary of the Number of Studies per Domain, Direction of Association, and Overall, Strength of Evidence.

Outcome Domain	No. of Studies	Direction of Association	Strength of Evidence
Caries experience	15	Higher fear ⇨ Higher caries	Moderate to Strong
OHRQoL	5	Higher fear ⇨ Poorer quality of life	Strong
Maternal fear impact	5	Maternal fear ⇨ Child fear/caries	Moderate
Oral hygiene / GI	4	Higher fear ⇨ Poorer oral hygiene / gingival index	Moderate
Child-specific factors	3	Past trauma, younger age ⇨ Increased fear	Moderate

TABLE 3: Domain-wise evidence tables This table presents the synthesis of evidence from 18 included studies categorized by major outcome domains. The number of studies, direction of association, and overall strength of evidence are summarized. Across most domains, higher levels of dental fear were consistently associated with adverse oral health outcomes, including increased caries experience, poorer oral health–related quality of life (OHRQoL), compromised oral hygiene, and greater maternal influence on child fear. Child-specific factors such as younger age and prior negative dental experiences were also observed to elevate DFA levels.

3.3   Synthesized findings:

Across 15 studies, higher DFA consistently correlated with increased caries experience. Five studies reported that DFA was strongly associated with poorer quality of life. Five studies highlighted the influence of maternal anxiety on children’s oral health outcomes. Four studies linked DFA with poorer plaque and gingival status. Three studies found that younger age and prior traumatic dental experiences predicted higher DFA.  Three studies found no significant association. Two studies had mixed findings, often influenced by moderating variables like socioeconomic status or parental anxiety. Common trends across studies revealed that children with higher DFA scores: Avoided or postponed routine dental visits. Had significantly higher DMFT/deft scores. Were more likely to present with untreated decay or dental pain. Displayed increased behavioral management issues during treatment. A study conducted in India noted that children whose CFSS-DS scores surpassed 38 exhibited nearly threefold higher odds of untreated dental caries compared to those with lower anxiety levels.¹² Another Brazilian cohort study showed that children who expressed fear of dental needles were significantly less likely to attend recall appointments²⁰. These findings are summarized domain-wise in Table Z, which synthesizes direction and strength of associations. The results can be visualized in figure 1. (A HARVEST

FIGURE 1. Harvest Plot Showing Distribution of Studies Examining the Association Between Dental Fear and Oral Health Outcomes

Figure 1: Harvest Plot showing the distribution of studies examining the association between levels of dental fear (High, Moderate, Low) and negative oral health outcomes (caries and oral health-related quality of life impact). The red bars represent studies reporting a negative oral health outcome, while green bars represent studies reporting no negative outcome. The plot highlights that most studies with high and moderate dental fear levels report adverse oral health impacts, whereas several studies with low dental fear report no negative outcomes.

Meta-Analysis: Two studies provided comparable data suitable for pooling. Both used the CFSS-DS scale to classify children as “anxious” (CFSS-DS > 38) and reported odds ratios for the presence of caries (DMFT > 0). Study 1: OR = 2.20 (95% CI: 1.05–4.60). Study 2: OR = 2.50 (95% CI: 1.15–5.10). Given the small sample size, a fixed-effects model was used, yielding a pooled odds ratio of 2.35 (95% CI: 1.28–4.34), which demonstrates a significant link between elevated dental fear and anxiety and the occurrence of caries. While the majority of studies could not be pooled due to heterogeneity, two studies using comparable criteria allowed limited meta-analysis. This suggests that anxious children were more than twice as likely to have dental caries than their non-anxious counterparts. Nevertheless, these findings should be viewed with caution because the Meta-analysis included only a small number of studies. (FIGURE :2-FOREST PLOT).

 

FIGURE 2. Forest Plot from Meta-Analysis Examining the Association Between Dental Fear/Anxiety and Caries in Children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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