The level of cooperation exhibited by children during dental visits is crucial for timely dental care and ongoing oral health maintenance. A lack of cooperation can lead to difficulties in receiving smooth examinations or treatments and foster negative memories of dental experiences, potentially causing an aversion to future dental visits [1]. Negative childhood dental experiences can cause fear in adulthood [2,3]. Consequently, eliciting good cooperation from children affects their oral health and development, and influences their perception of dental care in the long term, thereby significantly affecting their quality of life [4,5]. Therefore, understanding children’s behaviors to enable a more positive reception of dental experiences is critical for pediatric dentists.

Efforts to understand the behavior and cooperation of children in dental settings have a long history. The literature suggests that factors influencing children’s behavior during dental visits include age, maternal anxiety, socioeconomic status, medical history, and children’s perceptions of dental issues. Generally, younger children tend to exhibit more negative behaviors, and maternal anxiety is closely linked to uncooperative behavior in children. Moreover, children from families with lower incomes and educational levels often face difficulties in receiving regular dental care, leading to noncooperative behavior when dental issues necessitate a visit. Previous unpleasant experiences also contributed to children’s uncooperativeness in subsequent dental appointments, as did their awareness of their dental problems [6]. Furthermore, children’s personalities and temperaments can influence their behaviors. Therefore, evaluating broader aspects, including personality and temperament, may allow for a more precise prediction of cooperation and foster a more positive atmosphere in clinical situations.

This study aimed to evaluate various factors, including age, sex, medical history, temperament, dental fear, and guardian anxiety, and explore the correlation between these factors and children’s levels of cooperation during dental visits.

This study was approved by the Institutional Review Board (IRB) of Chonnam National University (approval no. CNUDH-2024-002).

Dentists treating children must fully understand the characteristics of young patients to foster cooperation during dental visits. This requires an assessment and understanding of children’s inherent temperaments and personality traits. In this study, we considered children’s personality traits, emotional characteristics, such as dental fear, and various other factors, including the extent of caries experience, sibling relationships, age, sex, frequency of visits, medical history, and guardians’ dental anxiety.

The factors associated with children’s cooperation during dental treatment in this study were dental fear (CFSS), the combined number of decayed, missing, and filled primary and permanent teeth (dmft +DMFT), and temperament traits of negative emotionality and shyness. The relationship between cooperation during treatment and dental fear revealed that children with less dental fear tended to cooperate more during dental visits. This finding aligns with the results of Alshoraim et al. [13] who reported that children with lower cooperation during dental examinations experienced greater fear than those with higher cooperation. El-Housseiny et al. [14] reported similar findings with a statistically significant correlation between the degree of dental fear and cooperation, with higher dental fear correlating with lower cooperation.

Meanwhile, as shown in Table 11, 19 children (31.1%) in the group with high CFSS scores showed cooperative behavior. This suggests that some children, despite having a high level of fear of dentists, can exhibit cooperative behavior during treatment for various reasons. These reasons include parental encouragement, a trusting relationship with dentists, and positive dental experiences. A study on dental fear in children and adolescents reported that even children with high dental fear could cooperate under certain conditions. They stated that nonthreatening and friendly communication techniques, as well as empathetic dental professionals, could significantly reduce anxiety and induce cooperation. Additionally, the use of gradual exposure approaches and positive reinforcement has been shown to be effective in managing dental fear and improving cooperative behavior [15]. Another study addressed the impact of dental professionals’ behavior on children’s dental fear and behavior. According to previous studies, even children with high dental fear can show cooperative attitudes in specific situations. This study emphasized that when dental professionals act understandingly and kindly, children’s dental fear is significantly reduced. Furthermore, the use of positive reinforcement, the “tell-show-do” method, and the creation of a child-friendly environment were found to make children feel more comfortable and less fearful. These strategies suggest that managing dental fear can be effectively aided using these methods [16].

Furthermore, an analysis of the relationship between the number of decayed teeth and children’s cooperation showed that the non-cooperative group had a higher number of decayed teeth. However, the number of decayed permanent teeth did not significantly affect the cooperation. This suggests that children who have received extensive dental treatment for caries exhibit less cooperative behavior during dental visits. This outcome can be interpreted as children who experience pain during dental treatments such as restoration or pulpectomy of the primary teeth showing lower cooperation. However, according to the results of the present study, there was no significant association between the number of decayed teeth and co-operation. Considering the outcomes of previous studies, these results can be interpreted as follows. First, as children grow, they develop both the physical and cognitive abilities to understand and practice oral hygiene on their own, having learned about the importance and habits of oral hygiene from home and school [17]. Second, the physical characteristics of primary teeth make them more susceptible than permanent teeth to external environments and substances. Therefore, the primary teeth are more prone to decay. Primary teeth have thinner enamel and are less mineralized than permanent teeth, making them less resistant to acid and bacterial attacks, thereby increasing the risk of caries [18,19]. Additionally, children’s growth can contribute to increased cooperation in dental settings. As children grow, transition to permanent teeth, and mature psychologically and emotionally, the association between permanent tooth decay and cooperation may weaken. Another study reported that as children age and their emotional regulation improves, dental anxiety and behavioral problems decrease [20]. Another study found that younger children (ages 4 - 6) tend to have higher anxiety and lower cooperativeness, whereas elementary school-aged children (ages 7 - 10) exhibit lower anxiety and higher cooperativeness [21]. Another study reported that dental anxiety and negative behaviors decrease with age, noting that higher anxiety is typically associated with younger children and linked to uncooperative behavior [22]. Meanwhile, a previous study on the relationship between dental anxiety and permanent tooth decay experience in adolescents found no association between dental anxiety and permanent tooth decay experience. This study focused on the relationship between the number of decayed teeth and cooperativeness in children, whereas the aforementioned studies dealt with dental anxiety as a variable. Therefore, a direct relationship between cooperativeness and the number of decayed teeth in children was not clearly observed. However, the results suggest that dental fear is significantly related to cooperation and should be considered together for a comprehensive understanding.

In a study by Prathima et al. [23], it was also reported that there was no correlation between dental fear and the DMFT (Decayed, Missing, and Filled Teeth) index or Gingival Index (GI) of permanent teeth among school-children aged 6 to 12 years, and that dental fear scores tended to decrease with age. Taani et al. [24] conducted a study on adolescents aged 12 - 15 years and reported no correlation between general dental fear and dental caries or gingivitis in permanent teeth. Similarly, Wong et al. [25] reported that dental fear was not significantly related to the experience of dental caries among adolescents aged 12 - 18 years.

These factors can serve as directions for interpreting the results of this study. Recognizing the importance of the significant changes that occur at each stage of a child’ s growth, future retrospective studies based on follow-up examinations may yield important insights.

According to Kroniņa et al.[26], a child’s dental experience is a factor that explains the variance in dental fear among children, with DMFT interpreted as an indicator of dental experience. Klingberg et al. [27] and Olak et al. [28] also suggested that children with high dental fear exhibit a higher rate of caries. Armfield et al. [29] noted that the fear of dentistry leads children to avoid dental visits, consequently neglecting oral healthcare. Schuller et al. [30] stated that increased dental fear is correlated with reluctance to visit a dentist, potentially leading to higher rates of caries and tooth loss. These findings suggest that children with high dental fear exhibit less cooperation during dental treatment and that this lack of cooperation is associated with a higher rate of caries.

This study also explored the relationship between children’s cooperation and their inherent temperament traits, negative emotionality, and shyness, finding that higher scores on these traits increased the likelihood of non-cooperation during dental procedures. This aligns with the findings of Gustafsson et al. [31] who suggested that children with high shyness scores tend to have behavioral regulation issues. Arnrup et al. [32] also reported that a child’s fear and temperament, especially negative emotionality, play a crucial role in differentiating levels of cooperation. Juárez-López et al. [33] found that activity was associated with reduced cooperation among children, although this finding was not significant in the present study.

Our findings indicated that age, sex, sibling relationships, birth order, and past hospital experience were not significantly correlated with children’s cooperation during dental procedures. This is consistent with the findings of Juárez-López et al. [33], who found no significant differences in behavior during dental treatment based on sex. However, this contrasts with the findings of Fazli et al. [34] who suggested that sex could be a helpful predictor of cooperation in a dental setting, with girls reportedly having higher levels of dental fear than boys. Considering these conflicting results, further research involving children from a broader range of sociocultural backgrounds is required.

Additionally, our study found no significant association between age and cooperation, which contradicts the findings of Juárez-López et al. [33] that children under the age of five tend to exhibit more negative behaviors. This discrepancy highlights the need for more extensive research to identify specific age groups that exhibit particularly good or poor cooperation. However, the analysis of the correlation between the independent variables revealed that age was associated with the level of fear. Specifically, the likelihood of showing a high level of fear decreased as the age approached 12 years. This result is similar to those of previous studies, which indicated that dental fear decreases over time in children aged 9 - 12 years [35].

Regarding the influence of a child’s upbringing or past hospital experiences, our findings suggest that these factors do not significantly impact a child’s cooperation in dental settings, similar to results from Kroniņa et al. [36]. They noted that a child’s medical experiences and socioeconomic factors do not explain the extent of dental fear. The study also observed that variability in birth order and number of siblings among participants might have affected the outcomes.

The analysis of the relationship between the type of past dental experience and cooperativeness in children (Table 12) indicated that children who had undergone dental treatment were more likely to be cooperative. Those who had only a dental check-up experience had an equal proportion of cooperative and uncooperative behaviors, while children with no dental experience were all uncooperative. This suggests that dental treatment experience may positively influence children’s cooperation. Specifically, children with treatment experience were more likely to be cooperative, indicating that dental experience can enhance their cooperation during dental visits. According to a previous study, children with no prior dental visit experience were more likely to develop dental fear and had greater fear during the visit than those with prior experience[37]. This study reported that experience with dentists reduced children’s fear and anxiety about dental pain.

Meanwhile, as shown in Table 12, 30 patients from the group with prior dental treatment were identified as uncooperative. These findings necessitate a more detailed analysis and interpretation of various factors affecting children.

Of these 30 children, 16 belonged to the group with high levels of dental anxiety. Despite multiple visits, these children exhibited low levels of cooperation because of significant dental anxiety. High dental anxiety can cause children to experience heightened levels of anxiety and stress during dental procedures, which, in turn, can lead to a decrease in cooperation. This is consistent with the results reported earlier in this study, indicating that higher dental anxiety is significantly associated with lower cooperation levels.

Among children with low dental anxiety, those who were still non-cooperative appeared to be influenced by certain temperamental factors. The analysis revealed that nine of these children had a high level of negative emotionality and four had a high level of sensitivity. Given that high levels of these temperaments are associated with significantly lower cooperation, as previously reported in this study, it is plausible that these temperamental traits could be the primary factors contributing to low cooperation despite prior treatment. Children with high levels of negative emotionality may struggle with emotion regulation, leading to increased anxiety or negative reactions during treatment. Similarly, children with a high sensitivity may respond excessively to external stimuli, resulting in increased discomfort during dental procedures.

In contrast, one patient did not exhibit any clear factors that negatively affected cooperation. This suggests that the patient’s previous dental experience was particularly negative, as indicated in previous research. Previous studies have shown that children’s cooperation during dental treatment is significantly influenced by discomfort and pain, with initial painful treatments potentially leading to fear and uncooperative behavior in subsequent visits [37]. Another study emphasized the critical importance of the initial dental experiences, noting that painful and negative experiences can reinforce dental fear and cause uncooperative behavior, whereas positive and comfortable experiences can enhance cooperation and reduce dental anxiety [38]. Repeated negative experiences may exacerbate children’s reluctance to visit dentists, ultimately resulting in reduced cooperation.

In conclusion, dental anxiety and children’s temperamental characteristics appear to be significant factors influencing cooperation. High dental anxiety and specific temperamental traits (negative emotionality and sensitivity) can serve as major contributors to uncooperative behavior, and negative past treatment experiences may contribute to decreased cooperation. This highlights the need for individualized approaches that consider these factors to improve cooperation and dental care outcomes in children.

Therefore, interpreting the results of this study based on previously reported findings, the equal proportion of cooperative and uncooperative behaviors in children who underwent only dental check-ups suggests that dental experiences can have varying effects on cooperativeness. In other words, extensive dental experience may help children adapt to the dental environment and increase cooperativeness through familiarity. However, the impact can vary depending on the nature of past experiences, potentially resulting in adverse effects.

Furthermore, in cases where children have no treatment or dental experience, they may experience fear and confusion because of their unfamiliarity with the dental situation. Additionally, uncooperative behavior in children within the dental environment can result from a combination of various factors. According to previous studies, the psychological state and behavior of children visiting the dentist are influenced by multiple factors, and not just a single one. It has been reported that the likelihood of experiencing fear and anxiety decreases with age [39]. Another study also observed that dental fear tended to decrease as age increased, suggesting that reactions can vary with age, even in the same dental environment [40]. This explains the variation in cooperativeness within groups of children categorized by type of dental experience, as children of different ages may be present in each group, leading to different levels of cooperativeness despite having similar experiences. The level of fear experienced in dental situations can differ depending on a child’s age, even with the same level of dental experience. Moreover, it has been reported that children with untreated caries or those who had their first dental visit at a later age exhibit higher dental fear. In other words, children who had not visited a dentist before but had experienced caries or who visited a dentist for the first time at an older age tended to experience greater fear [41].

Additionally, one study reported that children’s cooperation improved with increased dental treatment experience [42]. This study explained that children’s uncooperative behavior is due to anxiety about new experiences, which decreases as they become more familiar with the dental situation through repeated experiences. Therefore, the nature of dental experiences, whether positive or negative, can influence current cooperation. This highlights the importance of positive conditioning and experiences in dental treatment, suggesting that dentists should strive to minimize pain and discomfort to make children’s treatment experiences as positive as possible.

It should also be noted that the sample sizes for each type of dental experience were not uniform. For the groups that underwent only checkups or had no dental experience, the sample sizes did not meet the required numbers calculated using G*Power 3.1. According to the GPower 3.1 calculations (effect size = 0.3, significance level = 0.05, power = 0.8), each group required approximately 29 samples. Therefore, further analyses with a larger sample size are necessary.

Although not addressed in this study, parenting style is a critical factor influencing children’s cooperation. According to a previous study, parenting style is related to children’s dental fear, with 8-year-old girls raised in an authoritative parenting style showing significantly higher dental fear than those raised in a permissive style. As children age, the influence of parenting style on dental fear decreases [43]. Other studies have reported that authoritative parenting styles are associated with positive behaviors during dental visits, while authoritarian and neglectful styles are linked to negative behavior [44]. Another study directly reported on children’s cooperation and parenting styles, finding that children of authoritative parents were cooperative and exhibited positive behavior at the dentist, with lower caries rates, while children of permissive parents were uncooperative and exhibited negative behavior with higher caries rates [45]. Studies showing a direct relationship between fear and parenting style reported that an authoritarian parenting style is associated with reduced dental fear, whereas a permissive style increases dental fear [46]. Thus, most studies indicate that authoritative parenting styles are associated with positive behaviors in dental treatment, whereas permissive or authoritarian styles are linked to negative behaviors.

An increase in guardians’ dental anxiety was correlated with an increase in children’s dental fear, which is consistent with the findings of Coric et al. [47]. This suggests that the negative experiences shared by family members or friends can increase dental fear.

Meanwhile, an investigation into the factors causing dental fear among children revealed differences between the cooperative and uncooperative groups. Cooperative children were primarily concerned about physical discomfort and fear of unfamiliar environments, whereas uncooperative children were significantly influenced by physical sensations and dental treatment procedures. Therefore, it is important to apply tailored approaches to reduce dental fear in children. For cooperative children, efforts to create a friendly environment and to provide thorough explanations during treatment are necessary. Strategies to minimize noise and discomfort may be beneficial for uncooperative children.

Despite several limitations, including the demographics of children and guardians from Chonnam National University Pediatric Dentistry and the cross-sectional nature of the study, these findings provide insights into the factors affecting children’s cooperation during dental treatment. Future longitudinal studies should include more diverse and evenly distributed samples to better understand these factors.

Children’s cooperation during dental treatment is influenced by their inherent dental fear, personality traits (such as shyness and negative emotions), the number of decayed teeth during the primary and mixed dentition stages, guardians’ dental anxiety, and their experience with dental treatment.