BMC Oral Health BioMed Central

Research article Open Access

The Dental Neglect Scale in adolescents
Trilby Coolidge*1, Masahiro Heima2, Elissa K Johnson3 and
Philip Weinstein1

Address: 1Dental Public Health Sciences, University of Washington, Seattle WA, USA, 2Department of Pediatric Dentistry, School of Dental
Medicine, Case Western Reserve University, Cleveland OH, USA and 3School of Dentistry, University of Washington, Seattle WA, USA
Email: Trilby Coolidge* - tcoolidg@u.washington.edu; Masahiro Heima - mxh392@case.edu; Elissa K Johnson - elissj@u.washington.edu;
Philip Weinstein - philw@u.washington.edu
* Corresponding author

Published: 5 January 2009 Received: 12 September 2008

Accepted: 5 January 2009
BMC Oral Health 2009, 9:2 doi:10.1186/1472-6831-9-2
This article is available from: http://www.biomedcentral.com/1472-6831/9/2
© 2009 Coolidge et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Dental neglect has been found to be related to poor oral health, a tendency not to
have had routine check-ups, and a longer period of time since the last dental appointment in
samples of children and adults. The Dental Neglect Scale (DNS) has been found to be a valid
measure of dental neglect in samples of children and adults, and may be valid for adolescents as
well. We administered the DNS to a sample of adolescents and report on the relationships
between the DNS and oral health status, whether or not the adolescent has been to the dentist
recently for routine check-ups, and whether or not the adolescent currently goes to a dentist. We
also report the internal and test-retest reliabilities of the DNS in this sample, as well as the results
of an exploratory factor analysis.
Methods: One hundred seventeen adolescents from seven youth groups in the Seattle-Tacoma
metropolitan area (Washington State, U.S.) completed the DNS and indicated whether they
currently go to a dentist, while parents indicated whether the adolescent had a check-up in the
previous three years. Adolescents also received a dental screening. Sixty six adolescents completed
the questionnaire twice. T-tests were used to compare DNS scores of adolescents who have visible
caries or not, adolescents who have had a check-up in the past three years or not, and adolescents
who currently go to a dentist or not. Internal reliability was measured by Cronbach's alpha, and
test-rest reliability was measured by intra-class correlation. Factor analysis (Varimax rotation) was
used to examine the factor structure.
Results: In each comparison, significantly higher DNS scores were observed in adolescents with
visible caries, who have not had a check-up in the past three years, or who do not go to a dentist
(all p values < 0.05). The test-retest reliability of the DNS was high (ICC = 0.81), and its internal
reliability was acceptable (Cronbach's alpha = 0.60). Factor analysis yielded two factors,
characterized by home care and visiting a dentist.
Conclusion: The DNS appears to operate similarly in this sample of adolescents as it has in other
samples of children and adults.

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Background of this age had not been to the dentist in over a year [18].
Dental neglect, manifested in behaviors and/or attitudes In Norway, where dental care is accessible and free for
related to the undervaluing of oral health, has been found adolescents, the rates of adolescent dental avoidance may
to be a predictor of poor oral health in children and be as high as 12% or greater, and appear to increase from
adults, measured by indices of caries, toothache, and age 12 to 18 [17,19]. Adolescents who do not have regular
number of teeth lost, among others [1,2]. In addition to dental visits have significantly more caries than their
poor oral health, dental neglect is associated with peers. For example, a study of Norwegian adolescents (for
increased oral functional limitations and social and phys- whom access was not a barrier) found that 16.4% of those
ical disabilities [3]. When dental neglect is associated with who failed to visit the dentist had decayed, missing, and
avoiding professional dental care, individuals also have filled teeth (DMFT) scores more than one standard devia-
lowered perceptions of their overall quality of life [4]. tion above the mean, compared with 3.3% of non-avoid-
Thus, dental neglect in children and adults is associated ers [17].
with a number of negative outcomes in oral health and
overall functioning. Adolescents' increased autonomy may also mean that
they fail to practice adequate oral home health care. For
The Dental Neglect Scale (DNS, [1]) assesses the extent to example, they may elect to consume more snacks [11]. In
which an individual cares for his/her teeth, receives pro- additions, while most adolescents report brushing their
fessional dental care, and believes oral health to be impor- teeth twice a day, a significant number do not. Macgregor,
tant. It was originally composed of 7 items and developed Balding and Regis found that 28% of adolescent boys, and
for parents, who were directed to rate their child's behav- 14% of girls, brushed their teeth once a day, or less often
iors and attitude towards oral health. Children whose par- (percentages computed from data presented in [20]).
ents rated them as having higher dental neglect had more Taken together, these results indicate that some adoles-
caries and were less likely to have gone to a dentist in the cents are neglectful of their oral care, whether by failing to
previous two years than were children whose parents visit the dentist and/or by failing to maintain good home
rated them has having less neglect [1]. care practices.

A 6-item version of the DNS has successfully been used Since the DNS has been found to be associated with
with adults in several populations. Adults with greater poorer oral health and irregular dental attendance in pre-
neglect have more caries and fewer remaining teeth [5-7]. vious samples, it may be an appropriate measure for
Their dental attendance pattern is more irregular, less measuring dental neglect in adolescents. While the scale
likely to include recent check-ups, and marked by longer has been used in two samples which contained respond-
times between appointments [5,7,8]. Adults with higher ents aged 16 and older [6,7], to date its performance in
DNS scores also have poorer oral health quality of life, in adolescence alone has not been reported. Therefore, the
terms of the respondents' daily lives, social lives, and their primary aim of this study was to study the relationship
tendency to avoid speech due to concerns about their between DNS scores, oral health status, dental attendance
appearance [6]. for routine check-up, and going to a dentist in a sample of
adolescents. Inasmuch as test-retest reliability has only
Adolescence has been identified as a time when personal been reported for one sample [7], a second aim of this
oral health behaviors may be internalized and become study was to measure the test-retest reliability in the sam-
habits, as parents become increasingly less directly ple of adolescents. A third aim of the study was to measure
involved in their children's care [9,10]. Oral care during the internal reliability of the scale, as well as to carry out
adolescence is important for several reasons, including the an exploratory factor analysis of the items in the sample of
eruption of permanent dentition which increases the adolescents.
number of tooth surfaces which may decay, and an
increase in early periodontal disease [9,11]. Thus, adoles- Methods
cents may be at greater risk for dental disease during a This study was approved by the Human Subjects Division
developmental period when they are establishing oral of the University of Washington.
care habits.
Questionnaires
Dental avoidance is apparent in some individuals by ado- Two questionnaires were used in this study. The adoles-
lescence, as youth of this age are able to influence their cents' questionnaire contained several items, including
dental attendance [11-17]. In the UK, 48% of 16–24-year- the 6-item DNS. The adolescent answered each item on a
olds go to the dentist less frequently than they did 5 years 5-point scale, with answers ranging from "Definitely no"
previously [16]. A second study of 14–15-year-olds in to "Definitely yes" for each item. Possible scores range
England found that about 13% of boys and 16% of girls from 6 to 30, with higher scores indicative of greater den-

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tal neglect. The adolescents' questionnaire also included and whether or not the tooth was filled. The presence and
an item to determine whether the adolescent had a dental level of decay was rated according to a modification of the
office to go to as a measure of dental access, an item ask- WHO guide [21]. A tooth was rated as sound if there was
ing whether the adolescent currently goes to the dentist, no visible evidence of caries, as having moderate caries if
demographic questions, and others not reported here. The there was a visible loss of tooth substance (WHO score 1
second questionnaire, for parents, contained a question or 2), or as having severe caries if there was visibly under-
asking whether their adolescent had been to the dentist mined enamel (WHO score 3 or 4). Following the dental
for a routine check-up in the past three years. screening, the adolescent received a movie pass to thank
him or her.
Sample size
Using data from 16–24-year-olds in Norway [7], a sub- Study personnel returned to the youth centers weekly for
sample of 12 "high" dental neglect participants would be the next few weeks to collect data for the second question-
sufficient to find significant differences on mean DNS naire, as not all youth were present at each visit. The ado-
scores between this group and those with "moderate/low" lescents completed the questionnaire a second time, and
dental neglect, at 80% power with alpha set at 0.05. Pilot received a second movie pass. They also received a copy of
work by our group in middle and high schools in a neigh- their dental screening results after completing the ques-
boring area [unpublished] found that about 82% of ado- tionnaire, so that their answers would not be influenced
lescents had a dental office to go to. Skaret et al. [17,19] by learning the results of the screening. A copy of the
found that 12% of adolescents who had a dental office to results was sent to the parents. If the adolescent was not
go to avoided going to the dentist. Therefore, the sample present during any of the days of data collection for the
size target was set at 120–125, to be able to include second questionnaire, his/her dental screening results
approximately 100 adolescents with dental offices to go were mailed to him/her.
to, about 12 of whom would be likely to not go to a den-
tist and/or have higher DNS scores. Data analyses
Data were entered into the computer and checked for
Procedures accuracy. Only cases with complete data were included in
Directors of seven youth clubs in the Seattle-Tacoma met- the analyses. The data were analyzed with SPSS Version
ropolitan area (Washington State, U.S.) were invited to 14.0 (Chicago, IL). Each adolescent was given two caries
participate. The targeted clubs were located in urban, sub- ratings. First, adolescents were coded according to
urban, and a mixed rural/suburban area, and had youth whether they had any visible caries or not. Second,
members from a variety of racial/ethnic and socio-eco- because many adolescents had more than one carious
nomic backgrounds. All seven directors agreed to partici- lesion with varying degrees of severity, they were also
pate. Youth members attended these clubs on a drop-in coded according to the most serious caries rating given for
basis, and data collection was scheduled for the days and any tooth. For the second coding, adolescents were coded
times when directors predicted that the maximum as having no visible caries, moderate visible caries (at least
number of youth would be present. one tooth with WHO score 1 or 2 but no teeth with scores
3 or 4), or severe visible caries (at least one tooth with
Staff members at participating youth clubs distributed WHO score 3 or 4). In addition to descriptive statistics, t-
information about the study to parents who came to the tests were used to compare the DNS mean scores of males
clubs in person, and to other youth to take home to their and females, adolescents who had been to the dentist for
parents. Because the youth attended on a drop-in basis, a check-up in the previous three years or not, adolescents
staff members were not able to inform all eligible families who currently go to a dentist or who do not, and adoles-
about the study. Parents gave written consent, and adoles- cents who had visible caries or not. T-tests were also used
cents gave written assent. Parents who consented also to compare the six item means for adolescents who do or
completed the parental questionnaire and returned it with do not go to a dentist; to account for the multiple tests, the
the consent forms. At the first day of data collection, den- group-wise critical p value was 0.05, thus the critical p
tal and study personnel traveled to the location of the value for each t-test was set at 0.008 (0.05 divided by 6).
youth clubs. Adolescents who had completed the consent A one-way ANOVA was used to examine the overall rela-
process and who were present on the day of data collec- tionship between degree of dental caries (no visible caries,
tion completed the questionnaire. Following this, they only moderate caries, and severe caries) and DNS scores.
had a brief dental screening using light and mirror only. Post hoc tests were carried out using Tukey's Honestly Sig-
Calibrated dental personnel (who were not aware of the nificant Differences to account for the multiple tests.
adolescents' questionnaire results) rated each tooth Because the DNS scores were not normally distributed
(except wisdom teeth, as we did not expect all adolescents (most adolescents had lower DNS scores), Spearman's rho
to have these) for the visible presence or absence of decay, was used to analyze the relationships between age and

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DNS, and number of filled teeth and DNS. Intra-class cor- lower on these two items (t = 8.76, df = 106, p < 0.001 for
relation (two-way, mixed) was used to measure the test- item #2; t = 4.48, df = 106, p < 0.001 for item #3) than
retest reliability. Cronbach's alpha was used to examine adolescents who do not. There were no significant differ-
the internal consistency of the DNS, and a rotated (Var- ences on the other four items.
imax) factor analysis was used to explore the factor struc-
ture of the items. To control for the possible effects of Sixty six adolescents completed the DNS a second time.
differences in dental access, only adolescents with a dental Most (60%) of the adolescents completed the second
office to go to were included in the analyses which exam- questionnaire after an interval of one week, 31% com-
ined the relationships between DNS and caries, having pleted it after two weeks, and the remaining 9% com-
had a check-up in the past three years, and currently going pleted it after three weeks. The test-retest reliability (intra-
to a dentist. Data from the first administration of the DNS class correlation, two-way mixed) was 0.81 (p < 0.001).
were used for all analyses (except for the test-retest analy-
sis, which used data from both administrations). Validity analyses
Ninety seven (83%) of the adolescents stated that they
Results had a dental office to go to. Almost half (47%) of them
Sample demographic characteristics were male, and their mean age was 14.0 (SD = 2.1,
One hundred and twenty-six adolescents agreed to partic- median = 13, range = 12–18). Their mean DNS scores
ipate. Of these, 117 (92.9%) completed the DNS on the were 12.8 (SD = 3.8, median = 13, range = 6–23). There
first day of data collection and were included in the anal- were no gender differences for DNS scores in this subsam-
yses. Just over half (51%) were males. Their mean age was ple, and thus the males and females were combined for
14.3 years (SD = 2.1, range = 12–18). The age distribution the remaining analyses. DNS scores were positively corre-
was not normal (median age = 14 years, modal age = 12 lated with age (r = 0.297, p = 0.003).
years), and 58% of participants were aged 12–14 years.
Of adolescents who had dental offices to go to, 21% had
The mean DNS score for all of the adolescents was 13.2 not been for a check-up in the past three years, 19% cur-
(SD = 3.8, median = 13, range = 6–23). The mean score for rently do not go to a dentist, and 31% had visible caries.
males was 13.6 (SD = 4.2, median = 14, range = 6–23). For Table 2 shows the descriptive statistics for the mean DNS
females, the mean score was 12.8 (SD = 3.3, median = 13, scores for adolescents who have a dental office to go to
range = 7–23). These differences were not significant, and according to whether they had been to the dentist for a
therefore the males and females were combined for the check-up in the past three years, whether they currently go
remaining analyses. In the combined sample, age was to a dentist, and whether they had visible caries. Adoles-
positively correlated with DNS scores (Spearman's rho = cents who do have a dentist but who had not been to the
0.31, p = 0.001). dentist for a check-up in the past three years had signifi-
cantly higher DNS scores than those who had been for a
Reliability and factor analyses check-up (t = 2.94, df = 87, p = 0.004). Adolescents who
The internal reliability (Cronbach's alpha) of the DNS was have a dentist but who stated that they do not currently go
0.60. The exploratory factor analysis yielded two factors to the dentist had significantly higher DNS scores than
with Eigen values greater than 1, explaining 54.61% of the those who do go (t = 4.00, df = 88, p < 0.001). In addition,
total variance. Item loadings and total variance explained the DNS scores were significantly higher for those with
for the two factors are shown in Table 1. Four of the items visible caries than with those without visible caries (t =
(#1, 4, 5 and 6) fell on the first factor, and the remaining 2.17, df = 95, p = 0.032).
two items (#2 and 3) fell on the second factor. Adoles-
cents who currently go to a dentist scored significantly

Table 1: Results of Varimax Factor Analysis for Dental Neglect Scale (DNS) Items

Item Factor 1 Factor 2

1. I keep up my home dental care. 0.65 0.28

2. I receive the dental care I should. 0.17 0.84
3. (Reversed) I need dental care, but I put it off. 0.02 0.85
4. I brush as well as I should. 0.79 -0.05
5. I control snacking between meals as well as I should. 0.52 0.08
6. I consider my dental health to be important. 0.64 0.05
Eigen value 2.03 1.25
Variance explained 29.21% 25.40%

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Table 2: Dental Neglect Scale (DNS) Scores by Dental Attendance and Presence and Severity of Visible Caries in Adolescents Who
Have a Dentist

Had a Check-Up in the Past Mean DNS Score SD Median Range

Three Years
Yes (n = 70) 12.1 3.6 12 6–23
No (n = 19) 15.0 4.2 15 7–23

Currently Goes to a Dentist

Yes (n = 73) 12.1 3.5 12 6–21
No (n = 17) 15.9 4.0 15 11–23

Has Visible Caries

No (n = 67) 12.3 3.8 12 6–23
Yes (n = 30) 14.0 3.5 14 7–23

Worst Visible Caries

No Visible Caries (n = 67) 12.3 3.8 12 6–23
Moderate Caries (n = 24) 13.5 3.6 14 7–23
Severe Caries (n = 6) 16.2 2.4 15 14–20

Of the 30 adolescents with visible caries, 24 were coded to have visible caries, severe caries, and more filled teeth.
with moderate caries. The remaining 6 adolescents were These three criteria – dental attendance for routine check-
coded with severe caries. The descriptive statistics for the up, currently going to a dentist, and oral health status –
three groups (no visible caries, only moderate caries seen, have been described by previous authors as examples of
severe caries seen) are shown in Table 2. The DNS means criteria for the validity of the scale [1,5,7,8]. The fact that
of the three groups were significantly different from one these criteria were assessed by different methods (self-
another (F = 3.66, p = 0.029). Post hoc comparisons report, parental report, and clinical examination) adds to
revealed that the DNS means were not significantly differ- the evidence of validity [22]. In addition, we found evi-
ent between those adolescents with no visible caries and dence for the internal and test-retest reliabilities of the
those with moderate caries. However, those with severe DNS in our sample. Thus, it appears that the DNS has
caries had significantly higher DNS scores than the adoles- good psychometric properties when administered to ado-
cents with no visible caries (p = 0.038). lescents.

The number of filled teeth was summed to create a meas- DNS scores were significantly related to age, with older
ure of history of caries. Adolescents with higher DNS had adolescents having greater levels of dental neglect. Previ-
significantly more filled teeth (Spearman's rho = 0.22, p = ous studies of adults have found that the youngest adults
0.03). (aged 16–24 or 18–34) had higher DNS scores than either
all of the older adults, or all but the oldest group (65 and
Discussion older) [6-8]. In our sample, the modal age was 12 and
This is the first study examining the Dental Neglect Scale nearly 60% of the adolescents were aged 12 to 14. There-
in adolescents. Our research design involved a sample of fore, the fact that we found a positive relationship
convenience which may limit the generalizability of our between dental neglect and age may understate the actual
findings to adolescents in general. Nevertheless, our find- extent of an increase in middle and older adolescents as a
ings indicate that the Dental Neglect Scale appears to whole. The finding that older adolescents have higher
operate in similar ways in adolescents as it has been pre- dental neglect is consistent with that reported by Skaret et
viously found to act in samples of parents rating their chil- al. [19], who found that dental avoidance increased as
dren, young adults, and adults in general. adolescents age. This finding is troublesome, from a pub-
lic health standpoint, as it seems to imply that increased
We found that the degree of dental neglect in adolescents autonomy in adolescence may be associated with poorer
who have a dentist to go to was significantly related to oral health behaviors.
whether they had been to the dentist for a routine check-
up in the previous three years, according to parental The factor analysis yielded two factors, one which
report, as well as whether they currently go to a dentist included the three items concerning home care plus the
according to their own report. In addition, adolescents item assessing the respondent's overall view of the impor-
with greater dental neglect were significantly more likely tance of dental health, and a second factor which included

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the item about receiving dental care as well as the item In addition, because such moderate lesions are relatively
about putting off needed dental care. In our sample, den- small and symptom-less, an adolescent may be unaware
tal neglect related to home care appears to capture the first that he/she has one. On the other hand, adolescents with
factor, while neglect related to visiting the dentist appears severe caries are likely to experience symptoms. In addi-
to capture the second factor. These results are somewhat tion, a lesion corresponding to the WHO code of 3 or 4
different from two of the three previously-reported analy- has likely been developing for some time, and thus would
ses for adults and parents rating their children. Thomson be more likely to be seen in an individual who has not
et al.'s [1] factor analysis of the original 7-item scale been to the dentist for a year or longer [24,25]. Thus, our
yielded two factors, a general factor ("dental neglect") results support using the construct of dental neglect for
including all 7 items and a second factor ("avoidance of adolescents with more severe caries, but not for those with
care") for the two items regarding putting off needed care. moderate caries.
While Skaret et al. [7] reported that all 6 items in the adult
DNS loaded on one factor in a sample of adults aged 16 There are two potential weaknesses to our study. First, as
to 79 years, he did not find evidence for a second factor. noted above we used a sample of convenience in one geo-
In the third previously-reported analysis, Thomson and graphical area and thus the results may not be generaliza-
Locker [5] stated that the single item about putting off ble to all adolescents in that area or to U.S. adolescents in
needed dental care in the 6-item adult DNS did not load general. Second, for practical purposes the dental screen-
with the others in a sample of young adults. An examina- ings in this study were carried out with light and mirror
tion of their factor loadings indicates that the item about only. It is possible that some caries codings were errone-
receiving dental care loaded more highly with the second ous, since the dental personnel were not able to use prob-
factor, characterized by the item about putting off needed ing or x-rays. However, the fact that the coding scheme
dental care, than with the primary factor (loadings of 0.84 required visible evidence of caries means that false nega-
vs. 0.31). Thus, our findings are fairly similar to this pre- tives (under-reporting) of caries were more likely than
vious study of young adults. false positives. Indeed, during the calibration it was not
uncommon for dental personnel to comment on the need
The results of our factor analysis also appear to be similar to be "conservative" in their coding, since they could not
to those recently reported by Sanders, Spencer and Slade use other measures to confirm their experience-based
[3], who created a 10-item scale of dental neglect. In their beliefs that the teeth were more seriously diseased than
factor analysis of responses given by adults aged 18 to 91, they appeared to be. Thus, a more comprehensive dental
5 items fell on a factor which they describe as capturing examination might have revealed stronger relationships
home oral self-care, while the other 5 fell on a separate between DNS scores and caries.
factor, related to visiting a dentist. In our sample, there
were significant differences between adolescents who do Given that our sample was small and one of convenience,
or do not go to a dentist only for the two items related to it would be desirable to conduct a follow-up study with a
visiting a dentist, which comprise the second factor. Thus larger, representative sample of adolescents. If the rela-
it appears that adolescents endorse similar attitudes with tionships that we observed between caries and DNS (as
regards to home oral self-care, whether or not they go to a well as between number of filled teeth and DNS) are rep-
dentist. However, since we did not explicitly measure licated, the DNS may be an adequate substitute for a clin-
home health care behaviors, it would be premature to ical screening of adolescents in certain circumstances such
state that adolescents who do not go to the dentist actually as community-wide assessments, just as it may be in adult
engage in home oral self-care behaviors to the same extent samples [5]. In particular, it may be useful in identifying
as their peers who do go to the dentist. adolescents likely to have severe caries. However, we agree
with Thomson and Locker [5] that additional validity
Skaret et al. [23] used the presence of severe caries as an studies should be carried out to further evaluate whether
indicator of dental avoidance in a sample of rural adoles- the DNS could perform this function.
cents, as this clinical finding appeared to indicate that an
adolescent had not received dental care in some time and It would be useful to understand what factors influence
had not sought out dental care even though he/she was adolescents to develop dentally-neglectful behaviors and
likely to be experiencing toothache or other symptoms. attitudes. It is of interest to note that some adolescents
We found that those with no visible caries and those with believe that they are the ones primarily responsible for
moderate caries responded similarly on the DNS, in terms maintaining their oral health, while others indicate that
of mean scores. On the other hand, those with severe car- others (such as parents and/or the dentist) have this
ies scored significantly higher than those with no visible responsibility [9]. Other researchers have noted that ado-
caries. Moderate carious lesions could be expected to be lescent dental locus of control is related to the number of
seen even in adolescents who go to the dentist regularly. dental visits that they have [26]. Perhaps adolescents with

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This study was supported by NIH/NIDCR grants DE016952, T32DE07132, related to severe untreated tooth decay in rural adolescents:
and U54 DE14254. The content of this manuscript is solely the responsibil- a case-control study for public health planning. Int J Paediatr
ity of the authors and does not necessarily represent the official views of Dent 2004, 14:17-26.
the National Institute of Dental and Craniofacial Research or the National 24. Mejàre I, Källestål C, Stenlund H: Incidence and progression of
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