Dental caries experience and uncooperative behavior during school-based oral examination among preschool children in Ha’il City, Saudi Arabia: a cross-sectional study

Uncooperative behavior during dental examination is common in early childhood and complicates the delivery of pediatric oral healthcare. Behavior of this kind is frequently attributed to dental fear and anxiety, but the two are distinct: behavior can be observed directly, whereas fear and anxiety are internal states that require self- or proxy-report. Describing observed behavior and the factors associated with it is a necessary first step in planning care for young children. This cross-sectional study assessed dental caries experience and the prevalence of uncooperative behavior during a school-based oral examination among five-year-old preschool children in Ha’il City, Saudi Arabia, and identified factors associated with that behavior. A stratified random sampling approach was used to select five-year-old children from public preschools across Ha’il City. Two calibrated examiners performed clinical examinations to record dental caries experience using the decayed, missing, and filled teeth (dmft) index. Clinical cooperation during the examination was assessed via the observational Frankl Behavior Rating Scale (FBRS), with scores 1 and 2 classified as non-cooperative behavior. One parent or guardian per child completed a structured questionnaire covering socio-demographic characteristics and the respondent’s own dental fear. Data were analyzed using bivariate screenings followed by a multivariable logistic regression model to identify factors independently associated with uncooperative clinical behavior. Out of 300 invited children, 263 completed all clinical and behavioral examinations (response rate: 87.7%). The overall caries prevalence was 73.0%, with a mean dmft score of 4.2 (± 3.8 standard deviation [SD]). Only 14.8% of the cohort had a history of dental visits. Based on the FBRS, 17.5% of the children demonstrated uncooperative behavior during the clinical evaluation. In the final multivariable logistic regression model, three factors were independently associated with uncooperative behavior: higher dmft scores (odds ratio [OR] = 1.18, 95% CI: 1.09–1.28), reported dental fear in the responding parent (OR = 2.45, 95% CI: 1.63–3.68), and a complete lack of prior dental experience (OR = 1.86, 95% CI: 1.14–3.02). Five-year-old preschool children in Ha’il City show a high burden of dental caries experience alongside a substantial rate of uncooperative clinical behavior. Greater caries experience, reported dental fear in the responding parent, and no previous dental visit were independently associated with uncooperative behavior. The Frankl scale records observed behavior and is not a measure of the child’s subjective anxiety, so these findings should be read as describing cooperation during examination rather than dental fear. Together these findings support consideration of earlier preventive contact with young children and their parents, although a cross-sectional design cannot establish that any programme would improve cooperation or oral health.