Validity and Reliability of the Brazilian Version of the Children’s Experiences of Dental Anxiety Measure (CEDAM)

ABSTRACT

Objective:  To test the validity and reliability of the Brazilian Portuguese version of the Children's Experiences of Dental Anxiety Measure (CEDAM).

Material and Methods:  The sample consisted of 80 pairs of parents and 9 to 12-year-old students at a public school in Ubá, Brazil. Children self-applied the CEDAM, Children's Fear Survey Schedule-Dental Subscale (CFSS-DS), and Child Perceptions Questionnaire (CPQ_8-10/CPQ_11-14), and were clinically evaluated at school. Parents were interviewed about the child's dental history, the Corah's Dental Anxiety Scale, and the Parental-Caregiver Perceptions Questionnaire (P-CPQ). Criterion validity was assessed using the Mann-Whitney/Spearman's correlation; construct discriminant validity was evaluated using the Mann-Whitney/Kruskal-Wallis test; construct convergent validity was examined using Spearman's correlation; and predictive validity was assessed using multiple logistic regression. The reliability was calculated by Cronbach's alpha and McDonald's omega coefficients.

Results:  About 80% had already been to the dentist. Overall, highly fearful children had higher CEDAM mean scores than those who were less afraid, demonstrating criterion validity. In CPQ_8-10 global ratings, those reporting "regular" oral health had the highest CEDAM scores compared to those reporting "very good", showing discriminant validity. For convergent validity, the CEDAM score was positively correlated with the CPQ_8-10 emotional well-being domain. Moreover, significant positive correlations were observed between CEDAM scores and P-CPQ total scores and P-CPQ emotional well-being domain scores. The predictive validity was indicated by the greater chance that younger children with previous experience of dental visits, who had avoided and cried during dental treatment, presented higher CEDAM scores. Cronbach's alpha of 0.93 indicated almost perfect internal consistency of the CEDAM.

Conclusion:  The Brazilian Portuguese version of CEDAM proved to be valid and reliable for application in 9 to 12-year-old children. Dental anxiety is more likely to be observed in younger children who have visited the dentist, avoided, and cried during dental treatment.

Keywords:
Dental Anxiety; Child; Surveys and Questionnaires; Data Accuracy; Validation Study.

Introduction

Dental anxiety affects one-third of children, who report some fear during childhood dental consultations [¹]. Dental fear makes it difficult to adhere to and complete dental treatment, compromising the child's oral health and quality of life [²-⁴]. Dental anxiety can last into adulthood, with anxious children more likely to seek dental care only in cases of pain.

Although fear and anxiety are abstract, it is possible to adequately and experimentally measure these behaviors through a set of psychological and statistical techniques [⁵]. The Cognitive Behavioral Therapy (CBT) has shown a positive effect in children with various anxiety disorders [⁶] and in reducing dental anxiety [⁷,⁸]. The Children's Experiences of Dental Anxiety Measure (CEDAM) is a self-report questionnaire, developed in English [⁹], based on a theoretical model of five areas, which is a short-term psychosocial intervention focused on the problem and which aims to evaluate the thoughts, behaviors, physical symptoms, and feelings experienced by children and adolescents aged nine to sixteen years old. Among the five areas that the model described covers are: life situation, relationships and practical problems; altered thinking; altered emotions; altered feelings and/or physical symptoms; altered behaviors or levels of activity [¹⁰].

Assessing the factors that play a role in children's dental anxiety enables clinicians to identify problem areas that may be maintaining the phenomenon and to understand how they can effectively manage or reduce anxiety in their patients [⁹,¹¹]. This type of assessment can also help inform and develop the patient's own understanding of why they are anxious [⁹,¹⁰]. The advantages of the CEDAM, over other available measures, are assessing experiences that anxious children specifically identify as central to their anxiety, and using accessible language and concepts appropriate for this population. The CEDAM could therefore act as a relevant clinical measure that can favor constructive communication and enable cooperation between the patient and dentists.

In our previous study, the original version of CEDAM was translated into Brazilian Portuguese and socio-culturally adapted for use in children, considering that there is not yet a validated version of the instrument [¹²]. Considering that childhood anxiety can reflect on dental treatment and contribute negatively to the child's behavior in the dental appointment, the present study aimed to evaluate the validity of the Brazilian Portuguese CEDAM by associating it with external criteria (dental fear and quality of life) and to test its reliability using statistical parameters of internal consistency. The use of a valid and reliable instrument is essential to identify the level of anxiety of pediatric patients to approach them properly, thus maximizing the success in care.

Material and Methods

This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statements guidelines [¹³].

Study Design

This cross-sectional, quantitative study is part of a major project approved by the Ethics and Research Committee of the Federal University of Juiz de Fora under the CAAE protocol 55005421.7.0000.5147.

Setting

This study was performed from September 2022 to April 2023. The data was collected with children at school, and remotely with parents, using a call through the WhatsApp app. A letter with a brief and explanatory text about the survey and the Informed Consent and Assent Forms was sent to the parents and children by the school. For those parents who agreed to participate, personal data were requested (telephone number to contact, best time for telephone interview) to complete the questionnaires through telephone interview (maternal education level, child’s dental history, Corah's Dental Anxiety Scale, and Parental-Caregiver Perceptions Questionnaire - P-CPQ).

Participants

The sample consisted of 80 pairs of parents and children, aged between nine and twelve years old, who were scholars at a public school in Ubá, Minas Gerais, Brazil. The inclusion criteria considered were the acceptance of the Informed Consent and Assent Forms, participation in all phases of the study, and completion of the questionnaires. Children who did not collaborate with data collection and parents who did not fill out any essential data, such as telephone number, were excluded.

The sample size was calculated based on the CEDAM score obtained from the validity study of Porritt et al. [⁹]. Considering a standard deviation of 3.73 (the higher value between nine to twelve-year-old children), a margin of error of 2%, a confidence level of 95%, and a sample loss of 20%; the required sample size was defined as 80 children, aged nine to twelve-year-old (20 of each age), and their respective parents, totaling 160 participants.

Variables

Outcome Variable

The Brazilian Portuguese version of CEDAM [¹¹], initially developed in English [⁹], was used to evaluate the dental anxiety experienced by children. The CEDAM is a self-report measure (taking around 5 minutes), composed of 14 multiple-choice items with response options on a 3-point Likert scale (scores 1 to 3). Total scores range from 14 to 42, with higher scores reflecting higher levels of dental anxiety.

Independent Variables

The following variables were collected with children at school. All questionnaires were self-completed on the same day. Prior information ensured that children would feel comfortable completing the questionnaire in the time required and that they would be safe to be as honest as possible.

Child’s Dental Fear

The child's dental fear was evaluated using the Brazilian Portuguese version of the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) [¹⁴], initially developed in English [¹⁵]. CFSS-DS is composed of 15 items, with response options in a Likert scale of five points, ranging from "not afraid" (score 1) to "very afraid" (score 5) [¹⁵,¹⁶]. The sum of the total score of CFSS-DS can vary between 15 and 75 points [¹⁴]. Based on previous studies, the following cutoff scores and classification were used: "low fearful children" (score <32) and "high fearful children" (≥ 32) [¹⁷,¹⁸].

Children’s Perceptions of their Oral Health-Related Quality of Life (OHRQoL)

Children’s OHRQoL was evaluated using the Brazilian Portuguese version of the Child Perceptions Questionnaire (CPQ) for children aged eight to ten years (CPQ_8-10) and eleven to fourteen years (CPQ_11-14) [¹⁹]. The self-applied questionnaires were developed initially in English [²⁰,²¹]. They were designed to assess the impact of oral conditions on the quality of life of children, in the past 4 weeks (CPQ_8-10) and 3 months (CPQ_11-14). Items of the CPQ used five-Likert-type scales, ranging from “never” (score 0) to “every day or almost every day" (score 4). The items were divided into four domains: oral symptoms, functional limitations, emotional well-being, and social well-being. A high score indicated a higher negative impact on the child's OHRQoL. There are also two questions regarding global perceptions of oral health and overall well-being, presented in a four-point response format for CPQ_8-10 and a five-point Likert-type scale for CPQ_11-14, respectively.

Clinical Evaluation of Children

The children were clinically examined for dental caries, dental trauma, gingivitis, and fluorosis by only one examiner, previously trained using the in-lux methodology. All examinations took place at the school, outdoors in daylight, but not in direct sunlight. The clinical exam was performed using a mouth mirror, gauze, and a ball-ended dental probe. Dental caries was evaluated using the dmft and DMFT indices [²²]. The presence of dental trauma (Trauma - Fracture) was computed when part of the coronal surface has been lost as a result of trauma and there is no evidence of caries in at least one deciduous or permanent tooth [²²]. The evaluation of gingivitis was based on the Community Periodontal Index (CPI), confirming the presence of gingivitis when at least one index tooth (16, 11, 26, 36, 31, 46) presented bleeding after probing [²²]. The Dean's index criterion was used to categorize the level of fluorosis as: 0, normal; 1, questionable; 2, very mild; 3, mild; 4, moderate; and 5, severe [²³]. Before the dental examination, all children received oral health instructions, and those diagnosed with oral diseases were referred for dental treatment by a letter to their parents.

The following variables were collected by telephone interviews with parents.

Child’s Dental History

The dental history of children was evaluated using a pre-structured questionnaire with nine questions about hospitalization and dental history, the child's behaviour during clinical exam and/or dental procedure, need of protective stabilization, dental anesthesia, crying and/or fear of the dentist, and parent’s perception of child dental fear, with “yes” and “no” answer options.

Parents' Perception of the Child's Oral Health-Related Quality of Life

The Brazilian Portuguese version of the P-CPQ [²⁴], originally developed in English [²⁵], was used to evaluate the perception of parents about the frequency of impacts of oral diseases on the quality of life of children. The 35 items are divided into oral symptoms, functional limitations, emotional well-being, and social well-being domains, with answer options ranging from "never" (score 0) to "every day or almost every day" (score 4). The answer "I don't know" scored 0 [²⁰,²¹], considering that when parents point out the alternative "I don't know" for an item, in most cases, children would answer "never" for that item. There are also two questions about the global perception of the child's oral health and overall well-being, with response options ranging from zero (0) to four (4) points. The total score was obtained by summing the scores of 35 questions and, for each domain, summing the scores of the specific items. The higher the score, the greater the impact of oral diseases on the child's quality of life.

Parental Dental Anxiety

The dental anxiety of parents was evaluated using the Brazilian Portuguese version of Corah’s Dental Anxiety Scale [²⁶], originally developed in English [²⁷]. The scale consisted of four questions about the aspects of dental appointment, with five response options ranging from 1 to 5 points. The total sum was used to classify participants as having no anxious response (score 4-5), slightly anxious (6-10), anxious (11-15), and highly anxious (16-20) [²⁷].

Statistical Analyses

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 23.0 (IBM Corp., 2015). IBM SPSS Statistics for Windows (Version 23.0, Armonk, New York, USA) and BioEstat. 5.3 (Mamirauá Institute for Sustainable Development, Belém, Pará, Brazil), with a 5% significance level. Normality was assessed using the Shapiro-Wilk or Kolmogorov-Smirnov tests, where appropriate. Descriptive statistics were followed by bivariate analyses, using, when applicable, Chi-square independence or Chi-square partition tests.

Criterion validity was tested by comparing the CEDAM scores between the categories of CFSS-DS (low fearful vs. high fearful) using the Mann-Whitney test. Spearman's correlation test was used to evaluate the association between CEDAM scores and CFSS-DS scores. Construct discriminant validity was tested by comparing the mean CEDAM scores across the categories of responses to global ratings of oral health and overall well-being of CPQ and P-CPQ questionnaires, using the Mann-Whitney or Kruskal-Wallis test, where appropriate. Construct convergent validity was evaluated by correlating CEDAM scores with CPQ and P-CPQ scores, using Spearman's correlation test. The association between the independent variables and the CEDAM score used as a dependent variable (> median 18) was tested in predictive validity using a multiple logistic regression model.

The reliability of the instrument was evaluated by floor and ceiling effects, and by calculating Cronbach's alpha coefficient and McDonald's omega coefficient. Coefficient values above 0.80 represent "almost perfect" internal consistency; 0.61 to 0.80, "substantial"; 0.41 to 0.60, "moderate"; 0.21 to 0.40, "fair"; ≤0.21, "slight" [²⁸,²⁹].

Results

Table 1 shows the personal and clinical characteristics of the evaluated sample. The majority of mothers had more than 8 years of education (92.5%). One tenth of children have already been hospitalized, while 78.8% have already been to the dentist. All of the latter allowed the dentist to examine their mouth, and 96.7% agreed to the dental treatment. On the other hand, almost one-fifth of children need to be held to perform the dental procedure (16.7%). More than one-quarter had already been anesthetized (26.7%), and 33.3% reported a fear of the dentist. There was no significant difference between age groups.

Table 1
Descriptive analysis: distribution of personal and clinical characteristics according to age groups.

	Age (in Years)
Variables	9-10	11-12	Total	p-valuec
	N (%)	N (%)	N (%)
Personal Data
Child Sex
Female	20 (50.0)	19 (47.5)	39 (48.8)	0.9636*
Male	20 (50.0)	21 (52.5)	41 (51.3)
Maternal Education Level
≤ 8 years	2 (5.0)	4 (10.0)	6 (7.5)	<0.0001*
> 8 years	38 (95.0)	36 (90.0)	74 (92.5)
Maternal Dental Anxiety [CORAH Score]
No anxious [score: 4 to 5]	14 (35.0)	11 (27.5)	25 (31.3)	0.1995†
Slightly anxious [6 to 10]	18 (45.0)	17 (42.5)	35 (43.8)
Anxious [11 to 15]	8 (20.0)	12 (30.0)	20 (25.0)
Child’s Dental Historya [Answer ‘yes’]
1 - The child has already been hospitalized	3 (7.5)	6 (15.0)	9 (11.3)	<0.0001*
2 - The child has already been to the dentist	31 (77.5)	32 (80.0)	63 (78.8)	<0.0001*
3 - The child let the dentist examine their mouth	28 (90.3)	32 (100.0)	60 (100.0)	<0.0001*
4 - The child allowed the dental treatment	28 (90.3)	30 (93.8)	58 (96.7)	<0.0001*
5 - It was necessary to hold the child for the dental procedure to be performed	8 (25.8)	2 (6.3)	10 (16.7)	<0.0001*
6 - The child has already been anesthetized	9 (29.0)	7 (21.9)	16 (26.7)	0.0047*
7 - The child cried during the dental treatment	12 (38.7)	10 (31.3)	22 (36.7)	0.1249*
8 - The child reports fear of the dentist	12 (38.7)	8 (25.0)	20 (33.3)	0.0497*
9 - You consider that the child is anxious	18 (58.1)	13 (40.6)	31 (51.7)	0.9580*
Clinical Data
Presence of at Least One Decayed Toothb
Yes	14 (35.0)	13 (32.5)	27 (33.8)	0.0245*
No	26 (65.0)	27 (67.5)	53 (66.3)
dmft score
0	10 (25.0)	15 (37.5)	25 (31.3)	0.0045†
1-2	15 (37.5)	11 (27.5)	26 (32.5)
3-4	10 (25.0)	4 (10.0)	14 (17.5)
≥5	5 (12.5)	1 (2.5)	6 (7.5)
Mean (SD)	2.3 (2.1)	1.2 (1.6)	1.8 (2.0)
DMFT Score
0	33 (82.5)	25 (62.5)	58 (72.5)	<0.0001†
1-2	7 (17.5)	10 (25.0)	17 (21.3)
≥3	0 (0.0)	5 (12.5)	5 (6.3)
Mean (SD)	0.2 (0.5)	0.9 (1.4)	0.6 (1.1)
Dental Trauma
Yes	2 (5.0)	3 (7.5)	5 (6.3)	<0.0001*
No	38 (95.0)	37 (92.5)	75 (93.8)
Fluorosis
Normal (DI=0)	37 (92.5)	38 (95.0)	75 (93.8)	<0.0001†
Questionable (DI=1)	2 (5.0)	1 (2.5)	3 (3.8)
Very mild (DI=2)	1 (2.5)	1 (2.5)	2 (2.5)
Gingivitis
Yes	3 (7.5)	3 (7.5)	6 (7.5)	<0.0001*
No	37 (92.5)	37 (92.5)	74 (92.5)

• CEDAM: Children's Experiences of Dental Anxiety Measure; CFSS-DS: Children's Fear Survey Schedule-Dental Subscale;
• ^*
  Chi-square independence test; †Chi-square partition test;
• ^a
  The percentage of questions 3 to 9 was calculated based on the responses to question 2;
• ^b
  Component “d” (decayed) of dmft/DMFT indexes;
• ^c
  p-values of the comparisons between values of the total sample.

The presence of at least one decayed tooth was observed in 33.8% of the sample, with 32.5% and 21.3% of the children presenting 1 or 2 decayed, missed, or filled teeth in deciduous and permanent dentitions, respectively. The presence of dental trauma, fluorosis, and gingivitis was observed in less than 10% of the sample. There was no significant difference between age groups.

The distribution of the CEDAM responses is shown in Table 2. Of 14 items, only 3 had the majority of responses as score 2 (items 5, 6, and 8), the others were predominantly answered as score 1 (lower anxiety). For the total sample, the prevalence of score 3 ranged from 1.3% to 25% for questions 9 and 6, respectively.

Table 2
Distribution of the answer options (score)a for CEDAM

Item	9 to 10 Years			11 to 12 Years			Total			p-value b
	Score 1	2	3	Score 1	2	3	Score 1	2	3
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
1	32 (80.0)	5 (12.5)	3 (7.5)	36 (90.0)	3 (7.5)	1 (2.5)	68 (85.0)	8 (10.0)	4 (5.0)	<0.0001
2	32 (80.0)	4 (10.0)	4 (10.0)	36 (90.0)	0 (0.0)	4 (10.0)	68 (85.0)	4 (5.0)	8 (10.0)	<0.0001
3	34 (85.0)	0 (0.0)	6 (15.0)	36 (90.0)	0 (0.0)	4 (10.0)	70 (87.5)	0 (0.0)	10 (12.5)	<0.0001
4	23 (57.5)	14 (35.0)	3 (7.5)	21 (52.5)	18 (45.0)	1 (2.5)	44 (55.0)	32 (40.0)	4 (5.0)	<0.0001
5	12 (30.0)	26 (65.0)	2 (5.0)	18 (45.0)	21 (52.5)	1 (2.5)	30 (37.5)	47 (58.8)	3 (3.8)	<0.0001
6	3 (7.5)	23 (57.5)	14 (35.0)	5 (12.5)	29 (72.5)	6 (15.0)	8 (10.0)	52 (65.0)	20 (25.0)	<0.0001
7	27 (67.5)	13 (32.5)	0 (0.0)	33 (82.5)	7 (17.5)	0 (0.0)	60 (75.0)	20 (25.0)	0 (0.0)	<0.0001
8	8 (20.0)	28 (70.0)	4 (10.0)	19 (47.5)	18 (45.0)	3 (7.5)	27 (33.8)	46 (57.5)	7 (8.8)	<0.0001
9	31 (77.5)	9 (22.5)	0 (0.0)	34 (85.0)	5 (12.5)	1 (2.5)	65 (81.3)	14 (17.5)	1 (1.3)	<0.0001
10	21 (52.5)	19 (47.5)	0 (0.0)	34 (85.0)	6 (15.0)	0 (0.0)	55 (68.8)	25 (31.3)	0 (0.0)	<0.0001
11	33 (82.5)	6 (15.0)	1 (2.5)	38 (95.0)	1 (2.5)	1 (2.5)	71 (88.8)	7 (8.8)	2 (2.5)	<0.0001
12	26 (65.0)	14 (35.0)	0 (0.0)	30 (75.0)	9 (22.5)	1 (2.5)	56 (70.0)	23 (28.8)	1 (1.3)	<0.0001
13	27 (67.5)	8 (20.0)	5 (12.5)	31 (77.5)	5 (12.5)	4 (10.0)	58 (72.5)	13 (16.3)	9 (11.3)	<0.0001
14	20 (50.0)	17 (42.5)	3 (7.5)	30 (75.0)	6 (15.0)	4 (10.0)	50 (62.5)	23 (28.8)	7 (8.8)	<0.0001

• CEDAM: Children’s Experiences of Dental Anxiety Measure;
• ^a
  The higher the score, the higher the level of dental anxiety;
• ^b
  p-values of the comparisons between values of the total sample (Chi-square partition test).

Table 3 shows the results of the criterion validity of the CEDAM, considering the dental fear assessed by CFSS-DS as an external criterion of comparison. Overall, highly fearful children had higher CEDAM mean scores than low fearful ones (21.5 vs 17.0, p=0.0011). Significant positive correlations were observed between CEDAM and CFSS-DS scores for age groups and the total sample, suggesting that the higher the child's dental anxiety, the higher their dental fear.

Table 3
Criteria validity: comparison between CEDAM and CFSS-DS.

CFSS-DS Mean (SD) Scores	CEDAM Score [4-48]
	9-10 Years		11 to 14 Years		Total
	N	%	N	%	N	%
Low Fearful (Score < 32)	14	17.4 (1.6)	15	16.6 (1.4)	29	17.0 (1.5)
High Fearful (≥ 32)	26	22.8 (5.9)	25	20.0 (6.6)	51	21.5 (6.3)
p-valuea		0.0007		0.1754		0.0011
CFSS-DS Xcores		rho = 0.66		rho = 0.44		rho = 0.56
p-valueb		<0.0001		0.0046		<0.0001

• CEDAM: Children’s Experiences of Dental Anxiety Measure; CFSS-DS: Children's Fear Survey Schedule-Dental Subscale; SD: Standard Deviation; [4-48]: Possible Variation of the CEDAM Score; rho: Spearman correlation coefficient;
• ^a
  p-value obtained from the Mann-Whitney test;
• ^b
  p-value obtained from the Spearman correlation test.

Table 4 shows the CEDAM mean scores according to global ratings of oral health and overall well-being, demonstrating the construct's discriminant validity. There was a distinct gradient in mean CEDAM scores across the categories of CPQ_8-10 global rating of oral health, whereby those reporting “regular” oral health had the highest and those reporting “very good” oral health had the lowest CEDAM score, on average (p=0.0009). Eight to ten-year-old children who reported “not at all” impact on overall well-being had higher CEDAM mean scores than those reporting “very little” and “some” impacts (p=0.0000). On the other hand, when considering parental perceptions of the child's overall well-being, higher CEDAM scores were found for those children whose parents reported having "very little" impact on overall well-being, compared to those who reported "not at all" (p=0.0323).

Table 4
Construct discriminant validity: comparison between CEDAM and global ratings of oral health and overall well-being.

	CEDAM Score [0-100]
Variables	9 to 10 Years		11 to 14 Years		Total
	N	Mean (SD)	N	Mean (SD)	N	Mean (SD)
Global Rating of Oral Health
CPQ8-10
Very good [score 0]	6	29.5 (1.2)a	-	-	-	-
Good [score 1]	16	33.8 (5.3)b	-	-	-	-
Regular [score 2]	18	40.6 (10.2)c	-	-	-	-
Poor [score 3]	0	-	-	-	-	-
		pa=0.0009
CPQ11-14
Excellent [score 0]	-	-	14	33.6 (9.8)	-	-
Very good [score 1]	-	-	22	33.5 (4.6)	-	-
Good [score 2]	-	-	4	42.0 (12.1)	-	-
Fair/Poor [score 3 and 4]	-	-	0	-	-	-
				pa=0.2704
P-CPQ
Excellent [score 0]	0		0		0
Very good [score 1]	39	20.6 (5.2)	40	18.8 (5.5)	79	19.7 (5.4)
Good [score 2]	1	-	0	-	1	-
Fair/Poor [score 3 and 4]	0	-	0	-	0	-
		-		-		-
Global Rating of Overall Well-Being
CPQ8-10
Not at all [score 0]	11	33.3 (4.8)a	-	-	-	-
Very little [score 1]	15	2.0 (0.0)b	-	-	-	-
Some [score 2]	4	3.0 (0.0)b	-	-	-	-
A lot [score 3]	0	-	-	-	-	-
		pa=0.0000
CPQ11-14
Not at all [score 0]	-	-	40	18.8 (5.5)	-	-
Very little/Some/A lot/Very much [score 1 to 4]	-	-	0	-	-	-
		-		-
P-CPQ (n=80)
Not at all [score 0]	34	20.0 (4.7)	36	19.0 (5.7)	70	19.5 (5.3)
Very little [score 1]	6	26.2 (6.7)	3	17.0 (1.7)	9	23.1 (7.1)
Some [score 2]	0	-	1	-	1	-
A lot/Very much [score 3 to 4]		pb=0.0323		pb=0.9790		pb=0.1191

• CEDAM: Children’s Experiences of Dental Anxiety Measure; SD: Standard Deviation; CPQ: Child Perceptions Questionnaire; [0-²⁰] Possible Variation of the CEDAM Score;
• ^a
  p-value obtained from the Kruskal-Wallis test (Student's t test);
• ^b
  p-value obtained from the Mann-Whitney test.

Table 5 shows the results of the construct convergent validity, using the correlation analysis between CEDAM scores with CPQ and P-CPQ scores. The CEDAM score was positively correlated with the emotional well-being domain of CPQ_8-10 (r = 0.41; p=0.0081). Significant positive correlations were also observed between CEDAM scores and P-CPQ total (r = 0.30; p=0.0053) and emotional well-being domain scores (r = 0.31; p=0.0048). There was no significant association between CEDAM and CPQ_11-14 scores.

Table 5
Construct convergent validity: examination of the associations between CEDAM, CPQ, and P-CPQ scores.

Variables	No. of Items	Range	Mean (SD)	CEDAM Score
				rho	p-value
CPQ 8-10 (n = 40)
Total [0-20]	25	2-22	8.7 (5.4)	0.29	0.0603
Oral symptoms [0-20]	5	1-7	3.8 (1.4)	0.12	0.4472
Functional limitations [0-40]	5	0-9	3.3 (2.8)	0.23	0.1415
Emotional well-being [0-148]	5	0-6	1.4 (1.6)	0.41	0.0081
Social well-being [0-24]	10	0-4	0.3 (0.9)	0.27	0.0846
CPQ 11-14 (n = 40)
Total [0-36]	37	0-5	3.7 (2.1)	0.15	0.3247
Oral symptoms [0-36]	6	0-4	1.6 (1.2)	0.12	0.4428
Functional limitations [0-52]	9	0-3	0.7 (0.9)	0.13	0.4236
Emotional well-being [0-132]	9	0-1	0.2 (0.5)	0.05	0.7174
Social well-being [0-24]	13	0	1.3 (0.8)	0.09	0.5397
P-CPQ (n = 80)
Total [0-32]	33	2-10	4.2 (2.1)	0.30	0.0053
Oral symptoms [0-32]	6	1-6	1.5 (1.3)	0.13	0.2238
Functional limitations [0-44]	8	0-4	0.8 (0.8)	0.16	0.1396
Emotional well-being [14-42]	8	1-7	1.8 (0.8)	0.31	0.0048
Social well-being [30]	11	0	-	-	-

The results of the predictive validity are shown in Table 6. Multiple logistic regression analysis revealed that younger age (9-10 years) (OR = 0.18), previous visit to the dentist (OR = 40.08), refusing to collaborate with dental treatment (OR = 19.84), and crying during the dental treatment (OR = 9.13) were significant predictors of children’s dental anxiety (p<0.05). Approximately 60% of the variability in CEDAM scores above the median was explained by the variables mentioned above, according to the multiple logistic regression model.

Table 6
Predictive validity: Multiple logistic regression considering the total CEDAM score>median 18 as the dependent variable (n = 80). Only independent variables with a p ≤ 0.25 were shown.

Independent Variables	Category	OR	95% CI	p-value	VIF	Tolerance
Intercept		0.55	2.06-3.26	0.660	-	-
Age (years)	9-10	0.18	0.38-2.96	0.011	1.22	0.822
Sex	Male	0.36	0.19-2.20	0.100	1.10	0.913
The child has already been to the dentist	Yes	40.08	0.41-6.96	0.027	3.85	0.259
The child allowed the dental treatment	No	19.84	0.09-5.87	0.043	3.93	0.259
It was necessary to hold the child for the dental procedure to be performed	No	0.15	0.20-3.88	0.078	1.99	0.504
The child cried during the dental treatment	Yes	9.13	0.68-3.74	0.005	1.72	0.582

The results of the reliability of the CEDAM are shown in Table 7. The overall score ranged from 14 to 38, with a mean of 19.8 and a standard deviation of 5.6. A floor effect was observed in 2.3% of participants, and there was no ceiling effect. For age groups, the CEDAM scores also showed substantial variability, with modest floor and no ceiling effects. The Cronbach's alpha for the total sample was 0.93, indicating almost perfect internal consistency, and for the age groups, it ranged from 0.91 to 0.94, indicating nearly perfect homogeneity of the items.

Table 7
CEDAM reliability: floor and ceiling effects, internal consistency.

Age	N	Variation of the score [33]	Floor Effect*	Ceiling Effect†	Mean (SD)	Internal Consistency
						Cronbach’s α	McDonald’s ω
9-10 Years	40	14-34	1 (2.5)	0 (0.0)	20.9 (5.5)	0.91	0.91
11-12 Years	40	14-38	1 (2.5)	0 (0.0)	18.8 (5.5)	0.94	0.95
Total	80	14-38	2 (2.5)	0 (0.0)	19.8 (5.6)	0.93	0.93

• CEDAM: Children's Experiences of Dental Anxiety Measure; SD: Standard Deviation; [⁹]: Possible Variation of the CEDAM Score;
• ^*
  % of respondents with score = 0;
• ^†
  % of respondents with maximum score.

Discussion

In the present study, the Brazilian Portuguese version of CEDAM was self-applied by a group of 80 children aged nine to twelve years. The influence of age on dental anxiety is still controversial in the literature. While Luoto et al. [³¹,³²,³⁴,³⁵] suggested that anxiety is reduced with the maturation of the child, other studies found higher anxiety scores in older children, which could be explained by previous experience with more invasive dental procedures and consequently unpleasant memories [¹²]. In the present study, younger children were found to have approximately 0.18 times the likelihood of CEDAM scores above the median; however, no difference was observed in relation to gender, corroborating the findings of Ribas et al. [³⁶]. This can be explained by the fact that CEDAM makes a more comprehensive assessment of how teeth have an impact on the anxiety of these children, encompassing useless thoughts, feelings, and behaviors [³⁴]. Other studies obtained divergent results, with girls showing higher anxiety scores than boys, which can be explained by the fact that girls express their emotions better [³⁷].

Predictive validity refers to the degree to which test scores (independent variables or confounding factors) influence scores on a criterion measure, typically assessed through multiple regression analysis and consideration of test bias. The multifactorial etiology of children's dental anxiety involves previous painful dental experience and dental fear of parents, which can compromise their adherence to dental treatment [¹⁸]. In the present study, the likelihood of reporting dental anxiety above the median was higher among children who had already visited the dentist, those who avoided dental treatment, and those who cried during the dental office visit. According to Majstorovic et al. [³⁸], some anxious children tend to exhibit aggressive behavior, which may manifest as tantrums, crying, freezing, or attempts to leave the dental chair. Other studies suggested that anxious children often miss dental appointments [³⁹] and may present worse oral health, such as a higher prevalence of untreated caries lesions and a lower quality of life [⁴⁰,⁴¹]. However, no differences were observed in relation to clinical data in the predictive validity analysis of the CEDAM.

Criterion validity establishes the validity of a measurement instrument by comparing it with external criteria, which is evaluated in this study by comparing the CEDAM scores across different categories of dental fear obtained from CFSS-DS scores. The higher CEDAM score among high fearful children, as well as the positive correlations between CEDAM and CFSS-DS scores, could be explained by the clear difference between fear of a dentist and the fearful behavior exhibited by children, because the behavior can be a result of their dental fear and their ability to deal with invasive situations [³⁹].

The concept of discriminant validity is an essential part of the measure's construct validation process. It refers to the ability of the proposed measure not to be modified by processes that are theoretically unrelated to the object of the questionnaire [¹⁸]. In the present study, quality of life criteria were established and tested using comparison tests with the CPQ and P-CPQ questionnaires. Higher mean CEDAM scores, that is, greater dental anxiety, were observed in eight to ten-year-old children who reported "regular" oral health, "not at all" impact on overall well-being, and whose parents rated as having "very little" impact on general well-being. In the study by Barbosa et al. [³⁹], the psychological variables, anxiety and depression, remained significant in both CPQ models and were associated with greater impacts on OHRQoL of children and preadolescents. Other studies have also suggested a link between emotional state and self-perceived oral health outcomes, with significant associations between low self-esteem and negative impacts on children's OHRQoL [⁴²]. The present outcomes and the findings as mentioned above could be explained by two hypotheses: a poor emotional well-being can 'cause' a poor self-perception of oral health, or a poor self-perceived oral health can contribute to a low emotional well-being [⁴³,⁴³].

Construct validity refers to how well a test measures the concept it was designed to evaluate, as well as how other similar measurements relate to the same concepts. In this study, the construct convergent validity was proved by the significant positive correlations found between CEDAM and the emotional well-being domain of the CPQ, except for eleven to twelve-year-old children.

This outcome corroborates the Ten Berge et al. [⁴⁴] study, which suggested that children can learn to control the way they exhibit their fear as they get older, and, subsequently, this can lead to a decrease in perceived and reported inappropriate behavior. On the other hand, Barbosa et al. [⁹] found a worsening of OHRQoL with increasing age, a fact that may be related to psychological factors since in this period of preadolescence, puberty occurs, during which adolescents experience social transitions and need to adapt to their changes in bodies and identities [⁴⁵,⁴⁶]. All these changes can influence and affect the quality of life. In addition, studies have indicated that these transitions, such as menarche and hormonal changes, as well as the prevalence of stressful life events [¹], can also decrease psychological well-being.

Internal consistency is a measure of reliability, and in this study, it was evaluated using Cronbach's alpha coefficient. Values above 0.80 represent good internal consistency; however, for the analysis of the domains, with a reduced number of items, values from 0.60 are acceptable [²]. In this study, the internal consistency was "almost perfect" for both age groups (0.91 to 0.94) and the total sample (0.93). Porritt et al. [³] found similar results in the validity study of the original version of CEDAM, demonstrating that the version obtained in the present study has a good internal consistency.

The potential of this study refers to the use of a translated instrument (CEDAM) that followed a careful protocol of translation and cultural adaptation widely used in the literature [⁴], ensuring the understanding of the instrument by the study population, which directly impacts the validation process and reliability test of the measure. Moreover, the other measures used proved to be valid and reliable in previous studies, reflecting the good psychometric properties of the instruments. The limitation of the research is the sample size, and further studies with a representative sample of the population, as well as with pediatric patients recruited from clinical settings, are needed to complement the present findings. Similarly, further studies are required to test the instrument's reproducibility, as well as other psychometric properties, such as responsiveness.

Conclusion

The associations with other patient-centred assessments, such as dental fear and OHRQoL, confirmed the validity of the CEDAM. The questionnaire also proved to be reliable, with coefficient values indicating almost perfect internal consistency among the items. In the evaluated sample, dental anxiety was more likely to be reported by younger children, who had visited the dentist, avoided, and cried during dental treatment. Finally, the Brazilian Portuguese version of the CEDAM proved to help measure the dental anxiety of 9 to 12-year-old children.

• Financial Support
  This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Acknowledgments

The authors thank the children and parents for their voluntary participation in this study.

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

• Academic Editor:
  Ana Maria Gondim Valença

Publication Dates

• Publication in this collection
  08 Dec 2025
• Date of issue
  2026

History

• Received
  26 Oct 2024
• Reviewed
  26 Mar 2025
• Accepted
  24 Apr 2025