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ORIGINAL RESEARCH Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 1  |  Page : 27-34
Evaluation of physiological and behavioral measures in relation to dental anxiety during sequential dental visits in children


Dept of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College & Hospital, Maduravoyal, Chennai 600 095, India

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   Abstract 

Anxiety is a special variety of fear, experienced in anticipation of threatening stimuli. While some research workers have said that the response of a child improves with the number of visits, many have felt otherwise. The present study is yet another effort to find the patterns of anxiety in children during sequential dental visits. The main aim was to determine the physiological and behavioral variations during sequential dental visits and its impact on age and sex. The study was conducted at the outpatient Department of Pedodontics and preventive dentistry, Meenakshi Ammal Dental College and Hospital, Chennai to evaluate the physiological and behavioural measures of stress and anxiety in children. One hundred and fifteen children, between four and eleven years of age who reported for dental treatment were selected for the study.

Keywords: Dental Anxiety, Physiological, Behavioral measures

How to cite this article:
Rayen R, Muthu M S, Rao CR, Sivakumar N. Evaluation of physiological and behavioral measures in relation to dental anxiety during sequential dental visits in children. Indian J Dent Res 2006;17:27-34

How to cite this URL:
Rayen R, Muthu M S, Rao CR, Sivakumar N. Evaluation of physiological and behavioral measures in relation to dental anxiety during sequential dental visits in children. Indian J Dent Res [serial online] 2006 [cited 2020 Feb 21];17:27-34. Available from: http://www.ijdr.in/text.asp?2006/17/1/27/29895

   Introduction Top


Anxiety and pain in humans have been addressed by poets, philosophers and biologists of every age and every culture. An understanding of the two phenomenon and of their worth to life processes has seemingly held the promise of facilitating the search for the antithetic conditions of pleasme, well-being and even euphoria [1].

Some psychologists feel emotion and emotional behavior are two distinct and separate entities. They hold the view that emotion is a construct for the underlying neural process of emotional behavior. Differences in emotional responsiveness between children and adults appear to be partly due to cortical immaturity and partly due to difference in endocrine output.

Anxiety is a special variety of fear, experienced in anticipation of threatening stimuli. What is essentially necessary is the quantification of anxiety before choosing the technique of behavior modulation. As stated earlier, anxiety does produce some physiological reactions. The two most commonly measured reactions include blood pressure and heart rate. Fortified with the first hand knowledge of the child's anxiety, choice of behavior modulation technique becomes easier. This paves the way to deliver best treatment to the child patient.

The present study is yet another effort to find the patterns of anxiety in children during sequential dental visits. In this study, factors such as the sex, age of the child, number of children in the family, history of unpleasant dental experience and the purpose of visit was interpreted. To find out whether factors such as age, sex of the child play a role in increasing or decreasing the anxiety has also been quantified through measurements of blood pressure, heart rate and oxygen saturation at various treatment procedures. This helps in gradation of behavior according to the level of anxiety. Behavior rating has been done with the help of Frankl behavior rating scale during sequential dental visits.

Studies conducted by Messer JG and Myers DR et al on anxiety related to dental treatments confirm that physiological changes occur in the body as a result of the anxiety and stress during dental treatment [2], [3]. While some research workers have said that the response of a child improves with the number of visits [4], [5], many have felt otherwise [6], [7]. Venham, Bengston and Cipes (1977) have found a complicated pattern of behavior change in multiple visits [8].

A total of one hundred and fifteen normal healthy children without any past medical history with age ranging from 4 years to 11 years were studied. Their blood pressure, heart rate and oxygen saturation was recorded in three visits. The parents were also supplied with a brief history form.

The aims ofthepresent study are

  1. To determine the physiological variations in children during the initial visit and how it changes in the subsequent visits.
  2. To determine the physiological and behavioral variations and its impact on age and sex.
  3. To determine the possible effect of sequential dental visits on the behavior of children before and after treatment.


The objectives of the study are that

  1. It may help in proper selection of behavior modulation techniques and apply the same on children.
  2. Through proper quantification of anxiety, gradations of behavior may be possible.



   Materials and Methods Top


This study was planned at the outpatient Department of Pedodontics and Preventive Dentistry, Meenakshi Annual Dental College and Hospital, Chennai to evaluate the physiological and behavioral measures of stress and anxiety in children. One hundred and fifteen children, between four and eleven yeas of age who reported for dental treatment were selected for the study. Of these 115 children, 42 were girls and 73 were boys. They were divided into four groups. First group included all children between 4 and 5 yeas (n=32) of age. The second group included all children between 6 and 7 yeas (n=24) of age. The third group included children between the ages 8 and 9 yeas (n=30) and the fourth group included children between the ages 10 and 11 yeas (n=29).

The subjects were grouped based on the age as follows: a child of 6 yeas and 4 months of age was included in the age group of 6-7 yeas, but a child of age 7 yeas and 8 months was included in the age group of 8-9 years. Even though the age group criteria falls in a wider range and there can be changes in physiological and behavioral parameters as the child matures our main objective was to analyze whether there exists a difference in physiological and behavioral changes of the same child during sequential visits to the dental environment for various dental procedures.

The subjects were selected on the basis of the following criteria

  • Presence of parents at the first visit.
  • Children with definite indications of oral prophylaxis, restorations and extraction thereby necessitating a minimum of three dental visits.
  • Absence of past and/or present mental and physical disorders.
  • No history of current episodes of medications.


Children with accompanying parents were included in the study because a brief history about the child and social background was elicited during the first visit. It included age of the child, number of children in the family, history of previous unpleasant dental experience, purpose of visit and socioeconomic status. Details of the procedures were explained to the parents and consent was obtained.

Treatment that required multiple visits necessitated the patients to attend the dental clinic for a minimum of three visits. Care was taken to include subjects who required supragingival scalings, simple restorative procedures and extractions. The study spanned over a period of 48 days.

The child's response was assessed using a combination of four measures: heart rate, blood pressure (systolic and diastolic), oxygen saturation and cooperative behavior.

The selected subjects were made familiar with the Welch Allyn-Multi Monitor, which was used to measure the various parameters in the study. Regard the patients waiting time and recording time the values were recorded on an average of ten minutes after the patient came to the clinic and the recordings for procedures were carried out only in the mornings and early afternoon before and after the procedure was completed. These physiological variables were recorded in the following sequence.

  1. When the patient was waiting in the reception area
  2. Following initial examination
  3. Before and after oral prophylaxis
  4. Before and after cavity preparation
  5. Before and after extraction.


Behavior rating scale adapted from the work of Frankl and coworkers was used to assess the child's behavior [Table - 3]. This was carried out at eight intervals stating from the reception area till the end of vaious treatment procedures. Parents were not allowed inside the operatory during the experimental procedures.

Student's paired t-test was used to calculate the p-value for the mean, standard deviation and test of significance of mean change between waiting in the reception area and after initial examination. The variables that were analyzed are diastolic pressure, systolic pressure, pulse rate, oxygen saturation and behavior score of the children. Even though oxygen saturation is not an instant physiological measure, assessment was done because there are no other studies taxied out to evaluate the relationship between anxiety and oxygen saturation and moreover it was an inbuilt parameter in the multimonitor which was utilized in the study. Similar test was used to calculate the mean, standard deviation and test of significance of mean change between before and after oral prophylaxis, before and after cavity preparation, before and after extraction.

One-way ANOVA was used to calculate the test of significance (p value) of all the mean change in values between different age groups. Multiple range test by Turkey-HSD procedure was employed to identify the significant difference between various age groups at 5% level for all the physiological and behavioral measures.

Student's independent t-test was used to calculate the p­value for the mean, standard deviation and test of significance of mean values between boys and girls for all the physiological and behavioral measures.

The behavior rating of the individual at various situations between different age groups are given in [Table - 4]. Waiting in the reception showed a highly significant difference (p <0.0001) between almost all groups i.e. III vs I and II, IV vs I and II, It vs I. After initial examination showed high significance (p <0.0001) between I vs II, III, IV age groups. Mean change also showed some significance (p0.007). Before and after oral prophylaxis showed high significance (p <0.0001) between I group vs II, III and IV groups. Before and after cavity preparation showed similar results as in oral prophylaxis. While behavior rating was considered for extraction between different age groups, results showed high significance (p <0.0001) between IV vs I and It groups, I vs If and III groups before extraction. After extraction also showed high significance (p <0.0001) between IV vs I and It groups, III vs I groups respectively.


   Discussion Top


Anxiety is one form of emotion, which is associated with a change in blood pressure and heart rate. The production of anxiety can be viewed from two different aspects. One is the psychoanalytical aspect and the other is the physiological aspect. Different renowned authors have studied both the aspects of anxiety from time to time [9]. They have proved that stress produces anxiety. This initiates a chain of physiological reactions which inturn produces variations in blood pressure and heart rate [9],[10],[11].

The results of this study clearly showed a significant change in the systolic pressure and heart rate in all the situations in the dental operatory area The most anxiety provoking situation was found to be the time before and after the extraction procedure, followed by the initial period of waiting in the reception area The diastolic pressure also showed a significant change (p=0.001) from the initial waiting period to the period after initial examination. Oxygen saturation remained unaltered. The above two parameters did not have any statistically significant values in the other procedures.

The average mean for each age group have been calculated for various procedures at periodic intervals. In this study, anxiety and stress did not show any significant difference between different age groups in any of the procedures. Since the comparative values and mean change was not statistically significant for the physiological parameters, it was not mentioned in the article. In comparing the physiological variables between boys and girls no significant difference was found during any of the observation periods. Only diastolic pressure showed a significantly higher value (P = 0.04) among girls while waiting in the reception area and before oral prophylaxis. Other parameters showed no change between boys and girls from the first visit to the third visit. In this study the diastolic pressure did not show any significant difference of values during the various treatment procedures or between different age groups. Moreover the test of significance did not show a highly significant result and this variation could be considered normal.

The above findings were supported by Sowjanya, Tandon and Tharian (1995) who assessed the physiological response to dental anxiety in children of 8-9 years age group at various intervals [12]. The mean systolic pressure, diastolic pressure and pulse rate while waiting in the reception was 98.22±8.19, 64.74±9.02 and 98.32±10.79 respectively. In our study the diastolic pressure was 63.2±7.6, systolic pressure was 96.1±10.8 and pulse rate was 97.4±12.9. The results when compared showed a very close correlation in all the three physiological parameters. In their study the physiological recordings were high at the time of local anesthesia administration whereas in our study the readings were high before the extraction procedure showing a significant correlation between the two studies. The reason for higher values at first visit could also be because of the use of a sophisticated looking apparatus which could create anxiety and act as a confounding factor to the obtained values. The values were recorded on an average of ten to fifteen minutes after the patient came to the clinic and the recordings were carried out between eight thirty in the morning and twelve thirty in the afternoon.

The results of the physiological parameters measured are in accordance with the study of McCarthy Laufer, Myers and Messer who concluded that heart rate and blood pressure acted as a reliable indicator of stress and anxiety. [2],[3], [13],[14]But a contradictory study done by Howard and Katcher denounced heart rate as an indicator of stress [15]. They found the heart rate to vary due to the physical movement of the individual during dental treatment. Another study, which contradicted our findings, was by Beck and Weaver who in their study showed that the anticipation of high stress dental appointment did not affect blood pressure, but altered the heart rate [16]. This observation may be due to compensatory reductions in stroke volume and/or peripheral vascular resistance and small sample size. However, in contrast to the findings of Beck and Weaver and Howard and Katcher our study showed that both heart rate and systolic blood pressure increased simultaneously.

In a country like India where basic health service is yet to reach millions, dental care is nothing but luxury. Visiting a qualified dental surgeon is beyond the means of most of the village people and urban poors. They have to depend either on government run hospitals or charitable institutions. The subjects of the present study consisted mainly of urban poors (47%) and village people. A negligible percentage consisted of children belonging to affluent classes. So, fear of unknown in children of older age groups (the school going and the circumpubertal groups) is not astonishing. Many of them had no history of previous unpleasant dental experience (80.9%) and had not even visited a dental surgeon. Most of the children reported to the dental clinic with the complaint of pain (27.8%), decay (23.5%), pain and decay (8.7%), swelling (4.3%) whereas the other problems with which they reported were dirt (8.7%), malocclusion (10.4%), dental check-up (4.3%) and others (12.2%). So anticipation of pain would have been more in these groups of children thereby resulting in an increased blood pressure, heart rate while waiting in the reception compared to that after initial examination.

Behavioral scores were rated at the same eight intervals used for measuring the physiological values. Behavior management techniques were not used when treatment was performed.

A statistically significant improvement in behavior was noted when the child was transferred from the reception area to the period after initial examination. Behavior scores before and after oral prophylaxis did not show a significant change. There was a statistically significant decrease in behavior during the cavity preparation (p = 0.001) and extraction (p=0.001) procedure. Thus the evaluation of behavior from one visit to the next was largely a result of clinical impression. The overall scores during subsequent visits revealed that there was an initial improvement in behavior during the first visit followed by a significant decrease in behavior during the second and third visit.

The above behavioral findings were contradictory to the findings of Koenigsberg and Johnson who assessed the behavior of 61 children of age range 6-7 years during 3 sequential visits to dental office [17]. The first visit included a clinical examination procedure and in the next two visits restorative procedures were performed. Behavior was observed at six different instances. The behavior of over one half of the children remained unchanged between succeeding appointments. There was no statistically significant improvement or deterioration in behavior between appointments. But in our study the behavior improved from the waiting area to the period after initial examination and remained unchanged after oral prophylaxis. In the next two visits, the behavior of the children significantly decreased (p=0.0001) in our study whereas it remained unchanged in their study.

The reason for the difference in the results of both the studies was that the initial dental visit included examination, diagnostic procedures and oral prophylaxis. More stressful experiences were introduced during subsequent appointments. In our study apart from restorative procedures, extractions were also performed. Behavior management techniques were not used during any of the procedures and hence the children were not able to differentiate between stressful and non stressful dental procedures. The behavior of a child in the preceding appointment did not allow for any prediction of the child's reaction in the future visits.

Studies by Taylor, Koenigsberg and Johnson, Moyer and Peterson, Toledano, Folayan and Castro showed that there was no relationship between age and dental anxiety, which were not in accordance to our study [17],[18],[19],[20],[21],[22]. Studies of Taylor, Ripa, Venham were supportive to our study, exhibiting a relationship between age and dental anxiety [18],[23],[24].

Ripa (1979) said that dental visit evoked some degree of apprehension or anxiety in almost all children and particularly in pre-school children [23]. Taylor, Moyer and Peterson (1983) said that the increased proportion of negative behavior during initial reaction in 3-4 year old may be explained by greater fear of unknown and greater separation anxiety [18]. Their study however found no difference in anxiety in older age groups. In western countries fear of unknown in older age groups is not very common because of their regular dental visits.

The increased proportion of negative behaviors during initial reaction, seen in our study from four to five years age groups may be explained by greater separation anxiety and greater fear of the unknown. These fears are expected to decrease in older children.

In comparing the behavior scores between boys and girls no significant difference was found during any of the observation periods.

In a study by Wright et al on 5-9 years old, girls had more dental anxiety than boys. This study was based on a pictorial dental anxiety scale [25] Based on an overall level of fear of dentistry Klein Knecht et al reported that girls rated themselves more fearful than boys. They also found that the greatest mean difference by gender of the participants appeared in response to the fear of needle and drill [26]. Moyer, Taylor and Peterson reported that male behavior was found to be superior to female behavior in older children, especially during the injection and operative phases of appointments [18].

The results of our study indicated that there was no statistically significant relationship between gender and dental anxiety. Our inference was in accordance with the earlier findings of Otto U, Milgrom P, Bailey, Talbot and Taylor, Johnson and Baldwin (Jr), Damle and Rodrigues [27],[28],[29]. The studies of Taylor, Moyer and Peterson, Alvesolo I et al . Cuthbert and Melamed showed that a relation existed between gender and anxiety [19], [30],[31].

The reason for contradiction in our study may be because of the unequal sample size distribution between boys and girls. The number of boys occupied almost three-fourth of the total sample size. Moreover, the sex distributions between different age groups were not equal.

Dental anxiety is a dynamic phenomenon, which evolves in a complex and variable manner as dental experience accumulates and reflects multiple interacting variables such as fear of unknown, anticipation of pain, maternal separation anxiety etc [32]. Our study did not point at any single factor as a cause for anxiety in children in the initial visit. As this study did not use any behavior management techniques the children were not able to cope with various dental procedures. The results also indicate that the dentist should anticipate the need for continued efforts to help the child cope with various procedures in the dental operatory right from their initial dental visit.


   Conclusions Top


The study confirmed that there is a direct correlation between the blood pressure and pulse rate during anxiety producing dental situations. So the rise in blood pressure should not be misinterpreted for the presence of hypertension. However the present study showed a significant increase in pulse rate and blood pressure in almost all the dental procedures when compared with normal. It could be because the treatment had been started without any behavior management.

Behavior scores showed a statistical improvement from waiting in the operatory to the period after initial examination. But an overall decrease in behavior was found from the analysis in the second and third visits. The younger age groups displayed more negative behaviors during the initial waiting period and during the operative and surgical phases of the appointment. There was no significant difference between the anxiety of the child and the sex of the individual.

From the results the following conclusions can be drawn.

  1. Most of the children were anxious on their initial visit for dental treatment. The most anxiety provoking situation in the dental operatory was the period of extraction followed by the initial waiting in the reception area.
  2. All children exhibited an improvement in behavior during the initial phase of examination, remained unchanged for oral prophylaxis and gradually decrease for the subsequent visits.
  3. Younger children tend to display a more negative behavior while waiting in the reception area and for the cavity preparation and extraction procedures.


The extent of anxiety a child experiences does not relate directly to dental knowledge, but is an amalgamation of personal experiences, family concerns, disease levels and general personality traits. Such a complex situation means that it is no easy task to measure dental anxiety and pinpoint etiological agents.

Through proper knowledge of the pattern of anxiety a child follows in sequential visits, a flexible behavioral management technique should be adopted [33]. Treatment schedules should be properly planned and adjusted keeping in mind the possible range of anxiety the child will exhibit after the initial introductory session.

 
   References Top

1.Stewart RE, Barber TK, 'Troutman KC and Wei SHY: Non Pharmacologic management of pain and anxiety In. Pediatric Dentistry. Scientific foundations and clinical practice, The C.V Mosby Company London, p 793­798,1982.  Back to cited text no. 1    
2.Messer JG: Stress in dental patients undergoing routine procedures, IDent Res, 56[4]:362 367,1977.  Back to cited text no. 2    
3.Myers DR, Kramer WS, Sullivan RE: A study of the heart action of the child dental patient, J Dent Child, 39: 99-106,1972.  Back to cited text no. 3    
4.Howitt JW, Stricker G: Child patient's response to various dental procedures, J Am DentAssoc.7:70-74,1965.  Back to cited text no. 4    
5.Venham L, Quatrocelli S: The young child's response to repeated dental procedures, J DentRes, 56: 734-738,1977.  Back to cited text no. 5    
6.Beck FM, Weaver JM: Blood pressure and heart rate responses to anticipated high stress dental treatment, J Dent Res, 60: 26 - 29,1981.  Back to cited text no. 6    
7.Koenigsberg SR, Johnson R: Child behavior during three dental visits, J Dent Child, 33 - 36,1975.  Back to cited text no. 7    
8.Venham L, Bengston D, Cipes M: Children's response to sequential dental visits, J Dent Res, 56:454-459,1977.  Back to cited text no. 8    
9.Darrow CW: Physiological and clinical tests of autonomic function and autonomic balance. PhysiolRev. 23:1, 1943.  Back to cited text no. 9    
10.Best CH, Taylor NB: The physiological basis of medical practice. The Williams and Williams and Wilkins Co, Baltimore, pages: 127-205,1945.  Back to cited text no. 10    
11.Hurlock EB: Child Development, (6th ed.) New York McGraw Hill, pages 197 - 202, 1978.  Back to cited text no. 11    
12.Sowjanya V, Tandon S, Tharian E: Physiological response to dental anxiety in children, J Indian Soc Pedo Prev Dent, 13: 13-17,1995.  Back to cited text no. 12    
13.Me Carthy FM: A clinical study of blood pressure responses to epinephrine containing local anaesthetic solutions, J DentRes, 36:132 -141,1957.  Back to cited text no. 13    
14.Laufer Rosenzweig D, Kurt A, Chosack A. Explanations as a means of reducing fear of dental procedures in children, The Alpha Omegan, 57:130 -133,1964.  Back to cited text no. 14    
15.Rosenberg HM and KatcherAH: Heartrate and physical activity of children during dental treatment, J Dent Res, 55: 648-650, 1976.  Back to cited text no. 15    
16.Beck FM, Weaver JM: Blood pressure and heart rate responses to anticipated high stress dental treatment, J Dent Res, 60: 26 - 29,1981.  Back to cited text no. 16    
17.Koenigsberg SR, Johnson R: Child behavior during sequential dental visits, J Am Dent Assoc, 85: 128-132,1972.  Back to cited text no. 17    
18.Mark Taylor H, Ira Moyer N and Devereaux Peterson S: Effect of appointment time, age and gender on children's behavior in a dental setting, J Dent Child, 106-110,1983.  Back to cited text no. 18    
19.Taylor MIL Peterson DS: Effect of length and number of appointments on children's behavior in a dental setting, IDent Child, 50: 353 -357,1983.   Back to cited text no. 19    
20.Toledano M, Osorio R, Aguilera FS, Pegalajar Children's dental anxiety: Influence of personality and intelligence factors, Int J Ped Dent, 5:23-28, 1995.  Back to cited text no. 20    
21.Folayan MO, Idehen EE, Ufomata D: The effect of sociodemographic factors on dental anxiety in children seen in a suburban Nigerian Hospital, hit J Ped Dent, 13: 20-26,2003.  Back to cited text no. 21    
22.CastroAM,Pinto LMCP,GonalvesMR.Percinoto C: Assessment of Children's Anxiety and Behavior throughout Preventive Dental Appointments. Universidade Est. Paulista Julio Mesquita, Ar4atuba, Brazil Seq #211 - Fear, Anxiety and Behavior. Presented at the 81st general session of the international association for dental research. J DentRes, Jun: 25-28,2003.  Back to cited text no. 22    
23.Ripa LW: Attitudinal and environmental influences on children's behavior in the dental situation. In management of dental behavior in children, Littleton Mass: P.S.G. Publishing company, Littleton, Massachuetts, pages 33 - 34, 1979.  Back to cited text no. 23    
24.Venham LL, Murray P, Gaulin Kremer E: Child rearing variables affecting the preschool child's response to dental stress, J Dent Res, 58: 2042 - 2045,1979.  Back to cited text no. 24    
25.Wright FAC, Lucas JO, McMurray NE: Dental anxiety in five to nine year old children, J Pedod, 4:99-115,1980.  Back to cited text no. 25    
26.K1einKnecht RA, Klepac RA, Alexander LD: Origins and Characteristics of fear of dentistry J AmDentAssoc, 86:842-848,1973.  Back to cited text no. 26    
27.Milgrom P, Coldwell SE, Getz SE, Wein Ramsay DS: Four dimensions of fear of injections, J Am DentAssoc,128:756-759,1997.  Back to cited text no. 27    
28.Johnson R, Baldwin (Jr) DC: Relationship of maternal anxietyto the behavior of young children undergoing dental extractions, J Dent Res, 47: 801 -805,1968.  Back to cited text no. 28    
29.Rodrigues JSL, Damle SG: Influence of maternal trait and dental anxiety on child behavior, J Indian SocPedo. PrevDent, Sep: 104 108, 1997.   Back to cited text no. 29    
30.Alvesalo I, MurtomauH, MilgromP, HonkanenA. Karjalainen M, Tay KM: The dental fear survey schedule: A study with Finnish children, hit J Ped. Dent, 3:193-198,1993.  Back to cited text no. 30    
31.Cuthbert ML, Melamed BG: A screening device: Children at risk for dental fear and management problems, J Dent Child, 432-346,1982.  Back to cited text no. 31    
32.Venham LL, Murray P, Gaulin Kremer E: Child rearing variables affecting the preschool child's response to dental stress, J Dent Res, 58: 2042 - 2045,1979.  Back to cited text no. 32    
33.Blinkhom AS, Kay EL Atkinson JM, Millar K: Advice for the dental team on coping with the nervous child, Dental update, 17: 415-419,1990.  Back to cited text no. 33    

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Correspondence Address:
R Rayen
Dept of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College & Hospital, Maduravoyal, Chennai 600 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.29895

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    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]

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[Pubmed] | [DOI]
17 Determinants of parents’ choice of a paediatric dentist: an application of factor analysis
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    Abstract
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