Excess hospital costs incurred by individuals with child abuse and neglect history in South Australia: A birth-cohort study.

Child abuse and neglect is a serious public health issue across the globe, with documented impacts on health, but the impact on hospital costs, at the population level, is unknown. We aimed to estimate the additional public hospital costs for emergency department visits and admitted patient hospitalizations, for persons with reported child protection concerns, from birth to 31 years and modelled to age 65. Using linked hospital data from 2003 to 2017 for a population birth-cohort of all individuals born in South Australia from 1986 to 2017, we estimated costs of public hospital care. Mean cost and cost differences (adjusted and unadjusted) in 2018 Australian dollars (AU$) were calculated for persons with child protection contact vs none, per person and at the population level. Persons with child protection contact had higher annualized mean hospital costs than those with no contact, with cost differentials increasing with age. Unadjusted differential cost per person was AU$338 (95% CI AU$204-AU$473) from birth to 12 years; increasing to AU$2242 (AU$2074-AU$2411) at ages 25 to 31 years, equating to an additional AU$124 (US$100) million for public hospital services from birth to 31 years, an 18% cost penalty (33% from 13 to 31 years). Modelled to age 65 years, excess costs were estimated at AU$415 (US$337, adjusted: AU$365 and US$296) million, a 27% cost impost. There is a considerable hospital cost penalty associated with persons with reported child protection concerns, especially from adolescence into adulthood, highlighting an opportunity for cost savings by preventive investment in effective early-in-life interventions.

Child maltreatment and emergency department visits: a longitudinal birth cohort study from infancy to early adulthood.

BACKGROUND: Child maltreatment (CM) is a serious global public health issue, with documented impacts on health. OBJECTIVE: To examine the association between different levels of CM concern, and Emergency Department (ED) visits from infancy to early adulthood. PARTICIPANTS AND SETTING: Individuals born in Adelaide, South Australia from January 1986 to June 2017 (N = 443,754). METHODS: Using linked administrative data, we examined frequency and adjusted rate ratios for all-cause and cause specific ED visits among individuals with varying levels of CM concern. RESULTS: Cumulative mean ED visits to age 14.5 years were higher for individuals with any CM concern, ranging from 10.2 to 14.8, compared with 6.4 in persons with no recorded CM concern. Adjusted rate ratios for ED visits varied from 1.26 (95% CI: 1.23-1.30) to 1.54 (1.48-1.60) in children (birth to 12 years), 1.98 (CI: 1.92-2.04) to 4.34 (CI: 4.09-4.60) in adolescence and 2.22 (CI: 2.14-3.48) to 3.48 (3.27-3.72) in young adults, increasing with severity of maltreatment concerns. ED visits coded as self-harm or poisoning, injuries, substance use or mental illness were particularly high, with incidence rate ratios mostly 3 to 15 times for mental health/substance related visits and 1.5 to 3.2 for other accidents or injury for individuals with any CM concern versus none. CONCLUSIONS: The high rate ratios for ED visits in children with CM concern, especially for self-harm, substance use and mental health during adolescence and adulthood highlights the enduring mental health needs of victims of child maltreatment, providing further impetus for prevention.

Educational strengths and functional resilience at the start of primary school following child maltreatment.

BACKGROUND AND OBJECTIVE: This study explored the associations between child maltreatment and functional resilience at school commencement, and investigated factors related to resilience separately for boys and girls. PARTICIPANTS AND SETTING: Children were part of a birth cohort of all children born in South Australia between 1986 and 2017 who had completed the Early Australian Development Census (AEDC) at about age 5-6 years when starting primary school (N = 65,083). METHODS: Multivariable logistic regression analysis was conducted with a subsample of 3414 high-risk children who had a maltreatment substantiation or investigation, with resilience defined as having well or highly developed strengths on the Multiple Strength Indicator of the AEDC. RESULTS: CPS involvement was strongly associated with poorer functioning at school commencement. Among high-risk children, 51.2% demonstrated resilience. Predictors of resilience in the multivariable model were being older, not having an emotional condition, and being read to at home. Risk factors were being male, living in rural or remote areas, having a physical or sensory disability, or having a learning disability. Boys who had been maltreated demonstrated few strengths and had less resilience than girls. Boys and girls who were read to regularly at home had more than three times the odds of showing resilience than children who were not read to at home. CONCLUSIONS: The early learning environment provides an ideal opportunity to identify and intervene to help those children who are struggling with school adjustment following familial maltreatment. Boys are likely to need additional help.

Temporomandibular dysfunction experience is associated with oral health-related quality of life: an Australian national study.

BACKGROUND: There are very few studies of the association between temporomandibular dysfunction (TMD) and oral health-related quality of life (OHRQoL) in a representative sample from the Asia-Pacific region. Accordingly, we aimed to quantify the association of TMD with OHRQoL dimensions and overall measurement scores in a representative sample of Australian adults while accounting for a range of confounders, and statistically estimating whether TMD experience is meaningfully associated with OHRQoL. METHOD: Australia's National Survey of Adult Oral Health 2004-2006 data were used. The outcome variables were the Oral Health Impact Profile (OHIP-14) domains and overall scores while the main exposure was self-reported Diagnostic Criteria Question for TMD. The analysis accounted for confounders including oral health status obtained from the oral examination, demographics, socioeconomics, health behaviours and health including perceived stress subscales of the PSS-14. We conducted complex samples analysis while using Cohen's f2 effect size to estimate whether the association is meaningful. RESULTS: TMD prevalence was 9.9% (95% CI: 8.4-11.6%) among 4133 Australian adults. TMD experience was associated with impairments to the seven OHIP-14 OHRQoL domains (P < .05) with higher impairments observed in physical pain (B = 0.82, 95% CI: .45-1.20, P < .001), psychological discomfort (B = 0.68, 95% CI: .29-1.06, P = .001) and psychological disability (B = 0.52, 95% CI: .20-.84, P = .001) in adjusted multivariate analyses. The difference in the mean OHIP-14 scores for those reporting TMD (Mean = 13.1, 95% CI: 12.0-14.0) and those who did not (Mean = 6.6, 95% CI: 6.0-6.8) was significant (t = 7.51, P < .001). In an adjusted multivariable model for OHIP-14 scores, TMD experience was associated with higher OHIP-14 scores (B = 3.34, 95% CI: 1.94-4.75, P < .001) where the Cohen's f2 was .022. Further, perceived stress subscales: perceived distress and perceived control were associated with TMD experience and OHIP-14 scores (P < .05). CONCLUSION: Lower OHRQoL was observed in Australian adults who reported TMD experience but with small clinical importance which might support considering TMD in regular dental care. The higher impairments observed in physical pain, psychological discomfort and psychological disability domains of OHRQL can help clinicians and researchers focus their attention on these domains. The confounding effect exhibited by the perceived stress subscale might support their inclusion in future TMD and OHRQoL research.

Association of Child Maltreatment With Risk of Death During Childhood in South Australia.

Importance: Child maltreatment is a prominent public health concern affecting 20% to 50% of children worldwide. Consequences for mental and physical health have been reported, but population-level estimates of risk of death during childhood that are adjusted for confounders have not been published to date. Objective: To estimate the association of documented child protection concerns regarding maltreatment with risk of death from infancy to 16 years of age. Design, Setting, and Participants: This case-control study was nested in a population birth cohort of 608 547 persons born in South Australia, Australia. Case children were those who died between 1 month and 16 years of age (with the death registered by May 31, 2019). Control children were randomly selected individuals from the same population who were alive at the age at which the case child died, matched 5:1 for age, sex, and Aboriginal status. Data were analyzed from January 2019 to March 2021. Exposure: Children were assigned to 1 of 4 child protection concern categories (child protection system notification[s] only, investigation[s] [not substantiated], substantiated maltreatment, and ever placed in out-of-home care) based on administrative data from the South Australia Department for Child Protection or were classified as unexposed. Main Outcomes and Measures: Mortality rate ratios for death before 16 years of age, by child protection concern category, were estimated using conditional logistic regression, adjusted for birth outcomes, maternal attributes, and area-based socioeconomic status. Patterns of cause of death were compared for children with vs without child protection concerns. Results: Of 606 665 children included in the study, 1635 were case children (57.9% male [when sex was known]; mean [SD] age, 3.59 [4.56] years) and 8175 were control children (57.7% male; mean [SD] age, 3.59 [4.56] years [age censored at the time of death of the matched control child]). Compared with children with no child protection system contact, adjusted mortality rate ratios among children who died before 16 years of age were 2.69 (95% CI, 2.05-3.54) for children with child protection system notification(s) only; 3.16 (95% CI, 2.25-4.43) for children with investigation(s) (not substantiated); 2.93 (95% CI, 1.95-4.40) with substantiated maltreatment; and 3.79 (95% CI, 2.46-5.85) for children ever placed in out-of-home care. External causes represented 136 of 314 deaths (43.3%) among children with a documented child protection concern and 288 of 1306 deaths (22.1%) among other children. Deaths from assault or self-harm were most overrepresented, accounting for 11.1% of deaths in children with child protection concerns but just 0.8% of deaths among other children. Conclusions and Relevance: In this case-control study, children with documented child protection concerns, who were known to child protection agencies and were typically seen by clinicians and other service providers, had a higher risk of death compared with children with no child protection service contact. These findings suggest the need for a more comprehensive service response for children with protection concerns.

Intergenerational transmission of child maltreatment in South Australia, 1986-2017: a retrospective cohort study.

BACKGROUND: The extent of intergenerational transmission of child maltreatment is unclear due to methodological limitations in previous studies. In this study, we aimed to examine factors associated with intergenerational transmission of child maltreatment and quantify its extent in a population sample over a 30-year period in South Australia. METHODS: In this retrospective cohort study, we used linked administrative data from the South Australian Birth Registry to identify dyads of mothers and their children both born in South Australia between July 1, 1986, and June 30, 2017. Three child protection system (CPS) outcomes (any CPS involvement, substantiated maltreatment, and time spent in out-of-home care) were computed from data obtained from the South Australian Department for Child Protection. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for child CPS outcomes according to their mother's CPS exposure. FINDINGS: 38 556 unique mother-child dyads were included. 458 (2·0%) of 23 437 children whose mothers had no CPS involvement in childhood had a substantiated report of maltreatment and 127 (0·5%) spent time in out-of-home care. By comparison, 970 (22·1%) of 4382 children whose mothers experienced substantiated maltreatment in childhood had substantiated maltreatment and 469 (10·7%) spent time in out-of-home care. After adjusting for potential confounders, children of mothers with any CPS involvement in childhood had an increased risk of CPS contact compared with children whose mothers had no CPS involvement; this risk was greatest for children of mothers who had both substantiated maltreatment and spent time in out-of-home care (HR 6·25 [95% CI 5·59-6·98] for any CPS involvement, 13·69 [10·08-16·92] for substantiated maltreatment, and 25·78 [18·23-36·45] for any time in out-of-home care). Risks of child CPS outcomes were substantially increased for children of mothers who had a first CPS notification under the age of 1 year or who had any CPS notification at age 13-17 years. INTERPRETATION: Children are at high risk of maltreatment if their mother experienced maltreatment as a child. Assisting survivors of childhood maltreatment, particularly female survivors, provides a crucial intervention opportunity to help prevent further child abuse and neglect. FUNDING: Australian National Health and Medical Research Council; Channel 7 Children's Research Foundation.

Child Maltreatment and Mortality in Young Adults.

BACKGROUND: Child maltreatment (CM) is a global public health issue, with reported impacts on health and social outcomes. Evidence on mortality is lacking. In this study, we aimed to estimate the impact of CM on death rates in persons 16 to 33 years. METHODS: A retrospective cohort study of all persons born in South Australia 1986 to 2003 using linked administrative data. CM exposure was based on child protection service (CPS) contact: unexposed, no CPS contact before 16 years, and 7 exposed groups. Deaths were observed until May 31, 2019 and plotted from 16 years. Adjusted hazard ratios (aHRs) by CPS category were estimated using Cox proportional hazards models, adjusting for child and maternal characteristics. Incident rate ratios (IRRs) were derived for major causes of death, with and without CPS contact. RESULTS: The cohort included 331 254 persons, 20% with CPS contact. Persons with a child protection matter notification and nonsubstantiated or substantiated investigation had more than twice the death rate compared with persons with no CPS contact: aHR = 2.09 (95% confidence interval [CI] = 1.62-2.70) to aHR = 2.61 (95% CI = 1.99-3.43). Relative to no CPS contact, persons ever placed in out-of-home care had the highest mortality if first placed in care aged ≥3 years (aHR = 4.67 [95% CI = 3.52-6.20]); aHR was 1.75(95% CI = 0.98-3.14) if first placed in care aged <3 years. The largest differential cause-specific mortality (any contact versus no CPS contact) was death from poisonings, alcohol, and/or other substances (IRR = 4.82 [95% CI = 3.31-7.01]) and from suicide (IRR = 2.82 [95% CI = 2.15-3.68]). CONCLUSIONS: CM is a major underlying cause of potentially avoidable deaths in early adulthood. Clinical and family-based support for children and families in which CM is occurring must be a priority to protect children from imminent risk of harm and early death as young adults.

Hospitalizations among children involved in the child protection system: A long-term birth cohort study from infancy to adulthood using administrative data.

BACKGROUND: Despite considerable health consequences of child abuse and neglect, there is limited evidence on hospitalizations in this population. OBJECTIVES: To describe frequency and reasons for hospitalization by lifetime child protection system (CPS) involvement. PARTICIPANTS: 608,540 children born from January 1, 1986 to June 30, 2017 in South Australia, Australia METHODS: Using linked administrative data on CPS involvement and hospitalizations, we descriptively examined cumulative incidence, cumulative count and reasons for hospitalization from infancy to early adulthood by CPS involvement. RESULTS: By 16.5 years of age, cumulative incidence of ever-being hospitalized was 58% (95% CI 58-58) for children with no CPS involvement and significantly higher (72% (95% CI 71-73) to 88% (95% CI 86-90), P < 0.001) among those with different levels of CPS involvement. Cumulative mean counts of hospitalizations were highest at every age for those placed in out-of-home-care (reaching 7.7 by 16.5 years), almost four times higher than for children with no CPS involvement (2.0 by 16.5 years). Most frequent reasons for hospitalizations were similar across CPS involvement in the early years. From adolescence through early adulthood, mental health, and 'injury, poisoning or toxic effects of drugs' were frequent reasons for hospitalization among individuals with CPS involvement. CONCLUSIONS: This study highlights the vulnerability of children who have been maltreated, or are at risk of maltreatment, and the urgency of implementing effective preventive strategies early in life including consideration of adequate responses of child protection services. Frequent hospitalizations for mental health and injury confirms the potentially preventable nature of these hospitalizations.

School Absenteeism Associated With Child Protection System Involvement, Maltreatment Type, and Time in Out-of-Home Care.

Greater school absenteeism is associated with numerous negative educational outcomes. We used a retrospective cohort design with linked administrative data on 296,422 children to examine the relationship between school absenteeism and child protection system (CPS) involvement. Children with substantiated maltreatment had 4.1 times more unexplained and problem absences than children with no CPS involvement. In multivariate analyses, children with substantiated maltreatment had significantly greater "chronic" truancy (OR = 3.41) and less "acceptable" levels of absences (OR = 0.74) compared to children with no CPS involvement. Greater absenteeism was seen for children with substantiated neglect and who had their first CPS notification earlier in life. Being in out-of-home care for 3+ years was a protective factor for children who had a CPS notification before age 5. Additional adversities had a strong additive effect with CPS involvement on absenteeism and chronic truancy. This study demonstrates the potential scope for reducing problem absenteeism and helps inform the public debate regarding how the type and timing of CPS involvement might ameliorate or exacerbate harm for children.

Lifetime risk of child protection system involvement in South Australia for Aboriginal and non-Aboriginal children, 1986-2017 using linked administrative data.

BACKGROUND: Child protection services exist to reduce potential harms from child maltreatment. Many jurisdictions produce annual data on child protection system (CPS) involvement, leaving a gap in knowledge of lifetime involvement. OBJECTIVE: To describe lifetime involvement in CPS, by type of contact. PARTICIPANTS: All 608,547 children born in South Australia (SA), Australia between 1986 and 2017. METHODS: A retrospective cohort design using linked administrative data to report cumulative incidence of CPS involvement from birth to age <18 (or June30 2017) by Aboriginal status. CPS involvement was categorised into notifications (3 levels), investigations, substantiations and out-of-home care (OOHC). Cumulative incidence curves were derived for 5 birth cohorts. RESULTS: Across childhood (to age <18 years), substantiated maltreatment was experienced by 3.2-3.6% of non-Aboriginal and 19-25% of Aboriginal children, 7 times reported annual substantiation rates. For most CPS categories CPS involvement increased until 2010, and was occurring earlier in life. By age 3, 0.5% of non-Aboriginal and 4.5% of Aboriginal children born 1986-1991 were the subject of a substantiation compared with 1.9% and 15% of non-Aboriginal and Aboriginal children, respectively, born 2010-2017. Incidence rates beyond age 3 were similar. OOHC contact was similar across cohorts, with ˜1.5% of non-Aboriginal and 12.7% of Aboriginal children ever-placed in care. CONCLUSIONS: Data linkage is an essential tool for understanding life course involvement with the CPS and describing trends not observable from annual snapshots. Such information is critical for burden of disease estimates, informing policy and monitoring CPS performance.

The role of cognitions in short-term temporal changes in dental fear among Australian adults.

OBJECTIVES: To determine if temporal changes in dental fear over a 4-month period are predicted by changed cognitive vulnerability-related perceptions of going to the dentist. METHODS: Australian adults (n = 484) completed mailed questionnaires at baseline and follow-up, containing measures of dental fear, cognitive vulnerability-related perceptions, dental services received, and possible aversive experiences during the study period. Change in dental fear was the main outcome measure, categorized as decreased (Fear- ), unchanged (Fear0 ), and increased (Fear+ ). RESULTS: Across the study period, 15.5 percent of people had Fear- , 73.4 percent had Fear0 , and 11.1 percent had Fear+ . In a multinomial logistic regression, after controlling for participant gender, income, time since last dental visit at baseline, dental fear at baseline and experiencing an aversive event, increased vulnerability-related perceptions were significantly associated with Fear+ (OR = 2.83, P < 0.001) while decreased vulnerability-related perceptions were associated with Fear- (OR = 0.17, P < 0.001). CONCLUSIONS: This study found, across a relatively short 4-month period, that increased vulnerability-related perceptions of visiting the dentist predicted increased dental fear while decreased vulnerability-related perceptions predicted decreased dental fear. More appropriate study designs, such as longitudinal designs, and longer follow-up periods are needed to determine the possible causal nature of these associations.

Perceptions of the dental profession: a comparative analysis through scale development.

Dentistry is a science-based profession that has a close interaction with people and society. However, despite this close interaction, perceptions of the dental profession by both patients and dental professionals have received little research attention. The purpose of this study was to compare the perceptions of dentists, dental students, and patients toward the dental profession through the development and testing of the Dental Profession Perceptions Scale (DPPS). The DPPS contains a total of 17 items measured on a 5-point Likert response scale. The DPPS showed excellent internal reliability (Cronbach's α = 0.92) and test-retest reliability (r = 0.93). Explanatory and confirmatory factor analyses of the DPPS showed that dentists', dental students', and patients' perceptions of the dental profession could be grouped according to 'status', 'human', and 'scientific' factors. There were no statistically significant differences between participants' DPPS total or sub-scale scores according to dental group, gender, or income. The DPPS developed can be used in future studies as a psychometrically sound measuring tool. Further studies should examine the factors that may affect the perceptions of the dental profession in different societies and cultures.

Third molor extractions among Australian adults: findings from the 2013 National Dental Telephone Interview Survey.

OBJECTIVES: To identify, over the previous 12 months, whether: (i) dental insurance is associated with a higher number of third molar extractions (TME); (ii) single versus multiple TME is associated with self-rated oral health; and (iii) TME when 18-25 years of age is associated with fewer days absent from work because of dental problems. METHODOLOGY: Australia's 2013 National Dental Telephone Interview Survey, which included: socio-demographics; and number of extractions, reasons for extractions, self-rated oral health and days absent from work because of dental problems, all in the past 12 months. RESULTS: The majority of TME recipients were female [56.6%, standard error (SE) = 6.0%], 18-25 years of age (63.0%, SE = 5.4%), held a tertiary qualification (73.9%, SE = 5.4%), had a total annual household income of ≥$60,000 (58.3%, SE = 6.4%), were dentally insured (52.6%, SE = 6.2%) and received multiple TME (60.9%, SE = 8.5%). Number of TME was associated with having dental insurance [B = 0.97: 95% confidence interval (95% CI): 0.5-1.5] and days of work absence because of dental problems (B = 1.10; 95% CI: 0.26-1.94). Receiving single TME versus multiple TME was not associated with self-rated oral health (B = -0.25; 95% CI: -0.76 to 0.25). Receiving TME when 18-25 years of age versus when older than 25 years of age was not associated with days absent from work because of dental problems (B = 0.48; 95% CI: -0.37 to 2.33). CONCLUSION: Dental insurance was associated with a higher TME count without improving self-reported oral health in the short-term. Using age as a justification for prophylactic TME might be questionable because, receiving TME when 18-25 years of age versus when older than 25 years of age did not reduce days absent from work because of dental problems.

Translation and validation of the Finnish version of index of dental anxiety and fear (IDAF-4C+) among dental students.

BACKGROUND: Dental fear accounts for 41% of the non-habitual dental attendance such as visiting only when in pain among adult Finns. Dentists should be able to recognize patients in risk for irregular attendance due to dental fear and measure their fear with valid and reliable instrument that capture the multidimensionality of dental fear. The study's aim was to translate the Index of Dental Anxiety and Fear (IDAF-4C+) into Finnish and test its reliability and validity. METHODS: The study population consisted of dental students in a Finnish university (n = 202). The IDAF-4C+ was back-and forward translated by experts as well as a native English translator, blinded to the original version. Reliability was assessed using Cronbach's alpha. Validity of the IDAF-4C+ was assessed against the Modified Dental Anxiety Scale (MDAS) using Spearman correlation coefficients and through the use of Exploratory factor analysis (EFA) and between genders using Mann-Whitney U tests. RESULTS: The reliability of the IDAF-4C+ was good, the Cronbach's alpha being 0.88. The IDAF-4C+ and MDAS and their subscales were correlated, with coefficients varying between 0.34 and 0.85. Correlations were stronger with the emotional and physiological components of the IDAF-4C+. EFA revealed one factor explaining 51.7% of the common variance (eigenvalue = 4.6). Women tended to have slightly higher mean scores than men (1.49 vs. 1.36, p = 0.247). CONCLUSIONS: The translation and localization of the Finnish version of the IDAF-4C+ can be considered as providing some evidence of the validity and reliability of the scale. It adds to previously used measures as it considers also the behavioral, cognitive and physiological dimension involved in dental fear.

Exploring and modelling impacts of third molar experience on quality of life: a real-time qualitative study using Twitter.

OBJECTIVES: This study had two objectives: (i) to explore and model domains describing the real-time impact of third molars (TMs) on quality of life (QoL); and (ii) to assess the percentage coverage, in some generic health-related quality of life (HRQoL) and oral health-related quality of life (OHRQoL) instruments, of the TM QoL domains identified in this study. METHODOLOGY: A global cross-sectional sample of tweets containing 'wisdom tooth' over a 1-week period retrieved 3,537 tweets. After random quota sampling, classification and filtering, only 843 tweets were included in the thematic analysis. A TM QoL model was constructed based on the associations of the identified domains. Domains for the selected generic HRQoL and OHRQoL instruments were plotted against the domains identified in the study to calculate the percentage coverage for each. RESULTS: The QoL domains identified were pain (n = 348, 41%), mood (n = 173, 20%), anxiety and fear (n = 54, 7%), enjoying food (n = 41, 4%), coping (n = 37, 4%), daily activities (n = 34, 4%), sleep (n = 24, 2%), social life (n = 19, 2%), physical health (n = 17, 2%), ability to think (n = 9, 1%), self-care (n = 8, 1%) and sporting & recreation (n = 2, <1%). The Assessment Quality of Life instrument (AQoL-8D) covers 87% of the TM QoL domains, while the rest of the HRQoL and OHRQoL instruments cover 33-60%. CONCLUSION: This study shows how Twitter can be used to obtain real-time QoL data, which might be used to model how TMs impact on QoL. The TM QoL domains identified in the study were generally under-represented among the generic OHRQoL instruments assessed while, the HRQoL AQoL-8D covered most of the TM QoL domains. The QoL domains identified in the study might be used to develop a new OHRQoL measure for TMs.

Stress and Academic Performance in Dental Students: The Role of Coping Strategies and Examination-Related Self-Efficacy.

Academic stress negatively affects students' performance. However, little is known of the processes that may be involved in this association. This study aimed to analyze how other variables such as coping strategies and exam-related self-efficacy could be related to academic stress and performance for dental students. An online survey, including measures of coping strategies, perceived stress, exam-related self-efficacy, and academic performance, was completed by undergraduate dental students in Madrid, Spain. Of the 275 students invited to take the survey, 201 participated (response rate 73.6%). Rational coping strategies (problem-solving, positive reappraisal, seeking social support) were negatively associated with perceived stress (ß=-0.25, p<0.01), whereas emotional coping strategies (venting negative emotions, negative auto-focus) were linked to increased academic stress (ß=0.34, p<0.01). Moreover, rational and emotional coping strategies were, respectively, positively (ß=0.16, p<0.05) and negatively (ß=-0.22, p<0.01) associated with students' exam-related self-efficacy, and this relation was found to be partially mediated by the students' perceived stress (ß=-0.30, p<0.01). Experiencing higher levels of stress during the examination period was found to be associated with poorer average grades (ß=-0.21, p<0.01), but students' exam-related self-efficacy partially mediated this relation (ß=0.23, p<0.01). Those students who perceived themselves as more efficient in completing examinations reported better grades. Using adequate coping strategies (i.e., rational coping) may help to reduce stress for dental students and, through their effect on exam-related self-efficacy appraisals, contribute to improved academic performance.

Translation and psychometric properties of the Swedish version of the Index of Dental Anxiety and Fear (IDAF-4C⁺).

Dental anxiety (DA) is a common condition, with significant medical, psychological, and social consequences. High-quality psychometric tools for the assessment of dental anxiety are necessary for clinical and research purposes. The aim of this study was to adapt the Index of Dental Anxiety and Fear (IDAF-4C(+) ) to the Swedish language and to explore the psychometric properties of the translated version. The study included a clinical sample (n = 414; 17-91 yr of age) and a non-clinical sample (n = 51; 19-47 yr of age). The scales used were the IDAF-4C(+) , the Single-Question Assessment of Dental Anxiety (SQDA), the Dental Fear Survey (DFS), and the Internal Health Locus of Control (IHLOC). The Swedish IDAF anxiety module showed a clear, one-dimensional structure, good internal consistency (Cronbach's alpha = 0.95), and adequate validity, as evidenced by strong correlations with the other DA measures (SQDA and DFS) and weak correlations with the IHLOC. In addition, the IDAF phobia module and the IDAF stimulus module were strongly correlated with the other DA measures. To conclude, the study shows promising findings for the reliability and validity of the Swedish translation of the IDAF-4C(+) , as a useful measure of dental anxiety in research and clinical practice.

Dental fear-related cognitive vulnerability perceptions, dental prevention beliefs, dental visiting, and caries: a cross-sectional study in Madrid (Spain).

OBJECTIVE: This study aimed to analyze the role that psychosocial elements may play concerning dental attendance and oral health in children. In particular, we explored the associations among dental fear-related cognitive vulnerability perceptions, dental prevention beliefs, the pattern of dental visits, and the number of decayed teeth. METHODS: A cross-sectional design was used to collect data from 250 Spanish schoolchildren who completed a questionnaire. Oral health status was evaluated by pediatric dentists. Statistical analyses were mainly based on binary logistic regression and multiple linear regression, which allowed us to test possible associations among variables as well as interaction and mediation effects. RESULTS: Children with more vulnerability-related cognitions (Adj. OR = 0.74 P < 0.05) and more unfavorable dental prevention beliefs (Adj. OR = 1.47 P < 0.01) were less likely to attend the dentist regularly. Moreover, the interaction between dental prevention beliefs and cognitive vulnerability perceptions was associated with more decayed teeth (ß = -0.13 P < 0.05). The irregular pattern of dental visit, associated with fearful and unfavorable dental prevention cognitions, accounted for 20% of the effects of these variables on dental caries. CONCLUSION: The combination of greater cognitive vulnerability-related perceptions and low awareness of the benefits of dental prevention increased the risk of dental caries. Children with this profile also tended to demonstrate a more inadequate pattern of dental attendance. Preventive oral health programs would benefit from considering the role of children's cognitions on their oral health habits and dental health.

Dental fear and expected effectiveness of destructive coping as predictors of children's uncooperative intentions in dental settings.

AIM: To explore the mechanisms by which some children select disruptive behaviours to cope with stressful dental events. In particular, the relationships between dental fear, expected effectiveness of destructive coping, and intentions of displaying uncooperative behaviours were analysed. DESIGN: Participants were 170 children who filled out a questionnaire survey. Descriptive statistics by gender and group age as well as comparisons of means were calculated. Spearman's rho correlation coefficients and binary logistic regression analysis were used to test hypotheses of the relationships among variables. RESULTS: Both dental fear and the expected effectiveness of destructive coping strategies were significantly associated with children's uncooperative intentions at the dentist. In addition, children who strongly endorsed the effectiveness of destructive coping strategies had a higher probability of uncooperative intentions as dental fear increased. In contrast, this relationship was not statistically significant among children who did not expect negative behaviours to be effective. CONCLUSIONS: Children's expectations about the effectiveness of destructive coping behaviours can help explain variations in the use of these strategies in stressful dental situations. Dental fear as well as children's inadequate expectancies about coping alternatives should be explored and targeted to prevent and modify uncooperative behaviour intentions at the dentist.

Predictors of dental avoidance among Australian adults with different levels of dental anxiety.

OBJECTIVES: It has been proposed that avoidance of dental visits might be the main determinant of poor oral health outcomes in people with high dental anxiety (HDA). This study aimed to determine the predictors of dental avoidance among people with HDA and also whether these predictors differed from those found in people with lower dental anxiety (LDA). METHOD: Study participants (n = 596; response rate = 41.1%) comprised a random cross-sectional sample of the Australian adult population who completed a mailed self-complete questionnaire containing items relating to the use and accessibility of dental services, trust in dental professionals, dental anxiety, dental experiences, self-perceived oral health, vulnerability-related perceptions of visiting the dentist, and psychological health. Multiple imputation was used to replace missing values and statistically significant variables in bivariate analyses were entered into a multivariable logistic generalized linear model. RESULTS: More than two-thirds of participants with HDA were currently avoiding or delaying a dental visit. Among people with HDA, dental avoidance was independently and significantly predicted by difficulty paying a $300 dental bill, having no or only little trust in the last-visited dentist, perceived treatment need and dental anxiety. Among people with LDA, only perceived treatment need and dental anxiety predicted avoidance. CONCLUSIONS: In addition to their high anxiety, a number of additional barriers to dental visiting were found for people with HDA. These barriers, especially cost and communication issues with dentists, need to be addressed to assist people with HDA obtain necessary, regular dental care.