Influence of Parental Dental Experience on Decision-Making for their Children's Treatment and Expectation of Sedation MethodsABSTRACT
Objective: To evaluate how parental previous dental experiences influence their children's oral health care and dental visits, as well as their expectations regarding sedation methods in pediatric dentistry.
Material and Methods: A descriptive cross-sectional study was conducted using an electronic questionnaire that collected personal and socioeconomic data, childhood dental memories, and parental expectations regarding sedation methods. The chi-square and Fisher's exact tests were used for statistical analysis.
Results: A total of 347 parents participated in the study. Among them, 88.8% reported having visited the dentist during childhood, and 27.4% experienced trauma during dental care. However, this was not associated with their children's fear of the dentist. Additionally, 34.9% of parents believed their past experiences influenced their children’s dental visits. Furthermore, 47.7% reported that they would allow the dentist to choose the type of sedative. Inhalation sedation with nitrous oxide and oxygen was the least accepted.
Conclusion: Parental dental experiences were not linked to the frequency with which they take their children to the dentist. However, their limited knowledge about sedation techniques may impact their acceptance of these methods in behavior management.
Keywords:
Pediatric Dentistry; Dental Anxiety; Behavior Control.
Introduction
Fear and anxiety are emotional and psychological conditions that are closely related, arising from a triggering stimulus [1]. Fear is considered an emotion resulting from an identifiable threatening stimulus, which is linked to behavioral reactions that may escalate into anxiety when suppressed. Anxiety occurs when the triggering stimulus is interpreted as a risk indicator or negative expectation about a future event, generating physiological responses that involve decision-making, such as confrontation or avoidance [1]. Despite scientific and technological advancements that allow for greater patient comfort during dental appointments, fear and anxiety remain commonly associated with dental care [2].
Dental anxiety can lead to delayed dental treatments or even complete avoidance of dental consultations, worsening oral health, and increasing the need for complex treatments that could have been prevented [3]. According to Thakur et al. [4], most patients with dental anxiety tend to postpone dental treatments. Fear and anxiety are also linked to behavioral management difficulties, manifesting as reluctance or inability to cooperate during dental appointments and commit to treatment. Additionally, negative experiences during childhood or adolescence can determine the individual’s perceptions of dental care in adulthood [5]. Several factors are associated with dental fear and anxiety, including age, social factors, parental dental anxiety, socioeconomic status, parental preparation before the appointment, and their expectations regarding the child’s behavior in the dental setting [6]. Traumatic experiences, limited exposure to dental visits, and fear of injections also contribute to dental anxiety [7].
Among pediatric patients, in addition to these factors, parental influence, known as parental modeling, plays a significant role. This concept is supported by several studies demonstrating a positive correlation between children’s fear and their parental dental fear, a phenomenon referred to as parental anxiety [1]. Parents or caregivers may directly or indirectly transmit negative emotions to children, such as aversion, nervousness, and, most notably, anxiety [2]. Furthermore, parents serve as behavioral models for their children, who attempt to replicate their attitudes in daily life, particularly their mothers [1,2].
In pediatric dentistry, conscious sedation is often indicated to manage children who present significant fear and anxiety, ensuring cooperation and safe treatment. Because parental consent is essential, understanding their perceptions and acceptance of sedation methods is critical. Previous studies have shown that most parents consider conscious sedation safe and prefer approaches that minimize distress while allowing their presence during treatment [8]. More recently, Salerno et al. [9] reported variability and knowledge gaps in parental acceptance of advanced behavior management techniques, including conscious sedation, especially among parents of children with special needs. Alanbari et al. [10] also observed high parental acceptance of moderate sedation and protective stabilization, although separation from the child remained a concern for many parents. Furthermore, innovative approaches such as intranasal sedation via mucosal atomizer devices have been perceived as safe and well accepted, particularly among parents with higher educational levels [11]. Similar findings from Jordan indicate that nitrous oxide sedation is one of the most acceptable methods among parents, reinforcing its role in pediatric dental care [12]. In addition, studies highlight that both negative and positive memories of dental treatment can strongly influence long-term dental fear and anxiety, underscoring the importance of early positive experiences [13]. These findings highlight the relevance of investigating parental expectations regarding sedation methods, as their attitudes may directly influence decision-making and the success of pediatric dental treatments.
Considering that childhood dental fear and anxiety are influenced by parental anxiety, this study aims to evaluate how parents' previous dental experiences play a fundamental role in their children's oral health care and dental visits in the Brazilian context. Additionally, the study assesses parents' expectations regarding the use of conscious sedation methods in pediatric dental treatment.
Material and Methods
Study Design and Ethical Clearance
A descriptive cross-sectional study was conducted with a non-probabilistic snowball sampling method. This study was approved by the Research Ethics Committee of the State University of Maringá - UEM (CAAE number 46414421.0.0000.0104).
Sample
The sample size was calculated using the formula for the difference between two proportions, considering 38% and 28% prevalence of individuals with negative and positive childhood dental experiences, respectively, based on a previous study [8]. The sample size calculation followed the methodology for survey studies, with a 95% confidence level and a 5% margin of error, assuming a population of 35.5 million children aged 0-12 years in Brazil, resulting in a total of 347 participants. The questionnaire formulation and the study design adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [9].
The target population included parents or guardians of children aged 0-12 years. All participants invited were given the option to participate voluntarily after reading and agreeing to the Informed Consent Form (ICF). Data collection was conducted individually via an electronic questionnaire developed by the authors in Google Forms, a tool available in Google Docs, and distributed to participants via messaging apps. Parents who did not agree to the ICF were excluded from the study.
Data Collection
The questionnaire was divided into three sections. The first section contained objective and open-ended questions covering personal information (age, biological sex, and whether the respondent worked in the healthcare field) and socioeconomic data (educational level and household income).
The second section focused on memories of childhood dental visits including questions such as: “Did you go to the dentist when you were a child?” (Yes/No), “Did you have any negative experience with a dentist in your childhood?” (Yes/No), “If yes, what was it?” (open-ended), “What is the first word that comes to mind when you remember going to the dentist as a child?” (open-ended), “Currently, how often do you seek dental care?” (Every six months/Once a year/Sometimes/Only in case of pain), “Do you have fear, anxiety, worry and/or nervousness before a dental care appoitnment today?” (Yes/No), “Do you believe your past experiences affect your child’s dental care?” (Yes/No), “Have you ever avoided taking your child to the dentist due to fear of their reaction?” (Yes/No), and “Is your child cooperative during dental appointments?” (Yes/No).
The third section focused on sedation objective questions included: “Would you allow any sedative method for your child in case of non-cooperative behavior during dental care?” (Yes/No) and “Which sedative method would you allow for your child?” (Oral medication/Nitrous oxide/Natural medication/General anesthesia/What the dentist suggests/Do not know). Another question was: “What do you expect from your child when using sedatives?” (That he-she sleeps throughout the procedure/That he-she remains awake but drowsy/That he-she does not remember the procedure). The last open-ended question was: “What would definitely prevent you from allowing dental procedures under sedation for your child?”
Although the questionnaire was not validated, a pilot study was conducted with 30 individuals to assess the clarity of the questions. Data were analyzed using Cohen’s Kappa test to assess response agreement. The study commenced after achieving 80% agreement rate. The final sample did not include participants from the pilot study.
Data Analysis
The variable “Did you have any negative experience with a dentist in your childhood?” (Yes/No) was used as an independent variable and analyzed in relation to the variable “Do you have fear, anxiety, worry, and/or nervousness before a dental care appointment today?” (Yes/No). In addition, the variable “Do you have fear, anxiety, worry, and/or nervousness before a dental care appointment today?” was used as an independent variable in the analyses of parental decision-making regarding the acceptance of different sedation methods for their children. Statistical analyses were performed using Jamovi software, using the chi-square test with a significance level of p < 0.05. Open-ended responses were qualitatively evaluated to identify the most frequently used terms.
Results
A total of 347 participants responded to the questionnaire, of whom 93.4% were female and 6.6% were male. Regarding education level, most participants had completed graduate studies and/or higher education (58.8%), while only 1.7% had not completed elementary school. Approximately half of the sample (51%) reported household income above four thousand Reais, and 43.5% reported having two children. Only 19.6% were healthcare professionals.
Most participants (88.8%) reported having visited the dentist during childhood, and 27.4% reported experiencing traumatic events during dental care (Table 1). These events were statistically associated with feelings of fear, anxiety, worry, and nervousness before dental appointments (Table 2). Regarding the frequency of dental visits, 36.9% of parents stated that they only seek dental care when experiencing discomfort or pain (Table 1). Parents who reported pre-appointment fear, anxiety, worry, and nervousness were more likely to have experienced traumatic events during childhood dental care (p < 0.001) and, at present, the majority reported seeking care only when in pain (p < 0.001) (Table 2).
Association between parental negative experience during childhood dental care and pre-appointment negative emotions.
In the caregivers' reports of their childhood dental experiences, 88 accounts were classified as negative. Among these, 24 were related to pain, 19 to anesthesia, 14 to tooth extraction, and 13 to inadequate preparation by the dentist. Words such as “noise,” “brutality,” “smell,” and “pain” were frequently mentioned in these narratives.
Regarding the impact of parents' past dental experiences on their children, 34.9% of respondents believed their previous experiences influenced their children's dental visits. Only 8.1% reported having avoided taking their child to the dentist due to fear of the child’s behavior, while 87.8% considered their child cooperative during appointments (Table 3). Concerning the reasons for seeking dental care, 88.2% of parents reported taking their children for scheduled visits, whereas 11.8% sought care only in response to pain or discomfort (Table 3).
When asked about sedation in the case of non-cooperative behavior, most parents (47.6%) stated they would allow the dentist to decide, while 28.8% were unsure. Inhalation sedation with nitrous oxide and oxygen was the least frequently chosen option (2.3%). The main reasons that would definitively prevent parents from authorizing sedation were the impossibility of being present during the procedure (34%), fear and discomfort due to lack of knowledge about the method (30.8%), and cost-related concerns (14.7%). Regarding expectations, 46.4% of parents expected their child to remain awake but with slowed movements, 38.3% preferred that their child sleep throughout the procedure, and 15.3% expected the child to have no memory of the procedure afterward (Table 3).
No significant association was found between parents' pre-appointment fear, anxiety, worry, or nervousness and their decisions regarding dental care or sedation for their children (Table 4). The association between parental dental anxiety and decision-making regarding sedation methods for their children is shown in Table 4. Parents who reported higher levels of dental fear and anxiety were less likely to allow sedation without their presence, and tended to rely more on the dentist’s recommendation rather than choosing a specific method themselves. Additionally, lack of knowledge about sedation options was more frequently reported among anxious parents, reinforcing the influence of parental emotional state on decision-making.
Association between parental dental anxiety and decision-making about sedation for children.
Discussion
Dental anxiety in children is a widely documented issue in the literature, influenced by multiple psychosocial and environmental factors [5-7]. However, few studies have analyzed the impact of parental dental anxiety on their children's oral health. The present study aimed to evaluate this influence within the Brazilian context, as well as parental expectations regarding sedation methods for their children. Various factors were analyzed in relation to dental fear and anxiety, including monthly income, sex, history of dental trauma, and frequency of dental visits [3,4,6].
The results of this study indicate that parents with dental fear continue to take their children to dental appointments, suggesting that their own negative experiences may primarily influence their personal behavior rather than directly reducing their children’s attendance at dental visits. Nevertheless, previous research has demonstrated that parental dental anxiety can still be transmitted to children and influence their behavior during treatment [14-17]. Kroniņa et al. [15] found that children’s dental anxiety is largely shaped by family-related factors, including parental fear and negative dental experiences. Similarly, Šimunović et al. [16] reported that children of parents with high dental anxiety are more likely to present non-cooperative behavior during dental care. Karibe et al. [17] also emphasized the role of vicarious learning, whereby children develop fear through observing their parents’ anxious reactions to dental procedures.
Although no formal correlation analysis was performed in this study, one possible explanation for the continued attendance of children at dental visits, even when parents experience dental fear, is that many parents attempt to protect their children from developing similar anxieties. By recognizing the importance of early dental care, parents may act preventively despite their own discomfort [1,2]. In addition, recommendations from healthcare professionals regarding early and regular dental visits may reinforce this protective behavior and contribute to familiarizing children with the dental environment [6].
The importance of preventive programs directed at parents has also been highlighted in the literature, as parental guidance and education play a key role in reducing children’s oral health risks and ensuring continuity of care. Such interventions can improve parental knowledge, promote healthier behaviors at home, and help prevent dental emergencies that may negatively impact both children and their families [18,19].
Dental fear is among the most common phobias worldwide, with various triggers depending on an individual’s previous experiences [5,6]. In the present study, the main fear-inducing factors included dental instruments such as needles, forceps, and burs; the sound of highand low-speed handpieces; and abrupt or rough movements by some dentists. These findings are consistent with previous research showing that early negative experiences can lead to persistent negative experiences and heightened anxiety in adulthood [13,20]. Cademartori et al. [20] also observed that children with negative dental experiences exhibited higher levels of dental anxiety in subsequent visits, reinforcing the importance of early positive experiences.
Regarding sedation procedures, most parents demonstrated trust in the dentist's expertise and opted for the sedative recommended by the dentist. This finding underscores the importance of the dentist in promoting a sense of security not only in the child but also in the parents [8,9]. However, the study also identified significant parental resistance to allowing sedation procedures without their presence, despite their confidence in the dentist's choice of sedative. Another crucial observation was the limited parental knowledge about sedation techniques. A considerable number of respondents preferred not to proceed with sedation and opted for nitrous oxide, despite its well-established safety and effectiveness [10-12]. This is consistent with the findings of Boka et al. [21], who reported that parents tend to favor general anesthesia over nitrous oxide sedation for pediatric dental procedures, which is likely due to the lack of information regarding the latter’s safety profile.
Additionally, the high prevalence of dental treatments performed under general anesthesia and the frequent reports of uncooperative or negative behavior among pediatric patients emphasize the lack of specific behavioral management protocols for these children. Developing evidence-based guidelines tailored to improve cooperation and reduce the need for invasive approaches could positively impact their long-term oral health outcomes [22-24].
This study has certain limitations. As a descriptive cross-sectional study using a non-probabilistic snowball sampling method, there was limited control over sample selection, as the questionnaire was distributed by participants to their knowledge, introducing potential biases. Another limitation of this method is the homogeneity of the collected data, as participants may share similar characteristics because they were recruited through a social circle. To mitigate these limitations, the authors attempted to distribute the questionnaire across diverse groups to include participants from different backgrounds, experiences, and cultures.
Given the relatively small sample size, further research is recommended to explore the association between parental dental anxiety and its impact on their children's dental experiences. Additionally, future studies should focus on parental expectations regarding sedation techniques, as these methods play a crucial role in pediatric behavior management and ensure positive dental experiences.
Conclusion
Parental dental experiences were not linked to the frequency with which they take their children to the dentist. However, their limited knowledge about sedation techniques may impact their acceptance of these methods in behavior management.
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Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Ana Maria Gondim Valença
