UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4177
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Braz Dent Sci 2024 Jan/Mar;27 (1): e4177
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Translation and cultural adaptation of the Children’s Experiences of
Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
Tradução, adaptação cultural e análise das propriedades psicométricas da
“Children’s Experiences of Dental Anxiety
Measure”
para uso em crianças brasileiras
Julia Henriques Lamarca dos SANTOS1 , Maria Beatriz Duarte GAVIÃO2 , Carolina STEINER-OLIVEIRA2 ,
Marco Aurelio Benini PASCHOAL3 , Aline Rogéria Freire de CASTILHO2 , Taís de Souza BARBOSA4
1 - Universidade Federal de Juiz de Fora, Faculdade de Odontologia. Juiz de Fora, MG, Brazil.
2 - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba, Departamento de Ciências da Saúde e Odontologia Infantil.
Piracicaba, SP, Brazil.
3 - Universidade Federal de Minas Gerais, Faculdade de Odontologia, Departamento de Saúde Bucal da Criança e do Adolescente. Belo Horizonte,
MG, Brazil.
4 - Universidade Estadual Paulista, Instituto de Ciência e Tecnologia, Departamento de Odontologia Social e Clínica Infantil. São José dos Campos,
SP, Brazil.
How to cite: Santos JHL, Gavião MBD, Steiner-Oliveira C, Paschoal MAB, Castilho ARF, Barbosa TS. Translation and cultural adaptation
of the Children’s Experiences of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese. Braz Dent Sci. 2024;27(1):e4177.
https://doi.org/10.4322/bds.2024.e4177
ABSTRACT
Objective: The Children’s Experiences of Dental Anxiety Measure (CEDAM) was originally developed in English
to assess important aspects of dental anxiety for children. The aims of the study were to translate and perform the
cultural adaptation of the CEDAM to Brazilian Portuguese. Material and Methods: The CEDAM consists of 14 items,
measured by a Likert scale of 3 points, that indicates the intensity of dental anxiety. The questionnaire was translated
to Brazilian Portuguese, back-translated to English, reviewed by an Expert Committee and pretested in 10 eight- to
twelve-year-old schoolchildren. Results: The Expert Committee Review compared the original, translated (T1, T2)
and back-translated (BT1, BT2) versions and recommended some changes in order to achieve good understanding
of the items. In the pretest, only question 8 was misunderstood by one child, i.e., the translated version was well-
understood by more than 85% of the participants. Conclusion: The Brazilian CEDAM was culturally adapted for
the evaluated population of children.
KEYWORDS
Child; Dental anxiety; Pediatric dentistry; Surveys and questionnaires; Translating.
RESUMO
Objetivo: A escala Children’s Experiences of Dental Anxiety Measure (CEDAM) foi originalmente desenvolvida
em Inglês para avaliar importantes aspectos da ansiedade odontológica em crianças. Os objetivos do estudo foram
traduzir e realizar a adaptação cultural da CEDAM para o Português Brasileiro. Material e Métodos: A CEDAM
consiste de 14 itens, medidos por escala Likert de 3 pontos, que indica a intensidade da ansiedade odontológica.
O questionário foi traduzido para o Português Brasileiro, retraduzido para o Inglês, revisado por um Comitê de
Especialistas e pré-testado em 10 escolares de oito a doze anos. Resultados: O Comitê Revisor de Especialistas
comparou as versões original, traduzida (T1, T2) e retraduzida (BT1, BT2) e recomendou algumas mudanças
a m de obter uma boa compreensão dos itens. No pré-teste, somente a questão 8 não foi compreendida por
uma criança, isto é, a versão traduzida foi bem compreendida por mais de 85% dos participantes. Conclusão:
A versão brasileira da CEDAM foi culturalmente adaptada para a população avaliada de crianças.
PALAVRAS-CHAVE
Criança; Ansiedade ao tratamento odontológico; Odontopediatria; Inquéritos e questionários; Tradução.
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Santos JHL et al.
Translation and cultural adaptation of the Children’s Experiences of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
Santos JHL et al. Translation and cultural adaptation of the Children’s Experiences
of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
INTRODUCTION
Dental anxiety is dened as an anticipation
of preoccupation with what might happen during
dental visit [1-3]. Dental anxiety compromises
children’s adherence to dental treatment, resulting
in greater oral problems and worse oral health-
related quality of life [4-7]. The early approach
to this phenomenon favors the organization of
dental treatment according to the real needs of
the child [7]. According to a systematic review,
dental anxiety affects 6 to 19% of children and
12 to 17% when only the child’s responses are
considered [2]. Additionally, anxiety decreased
as the age increased [8] as a consequence of
the increase in perceptive and adaptive capacity
to aversive stimuli from the environment and
circumstances.
The multifactorial etiology of dental anxiety
involves somatic, cognitive, and emotional
elements, which characterize a state of concern
that something bad may happen during dental
treatment, related to the feeling of loss of control [9].
Children with previous dental experience showed
less anxiety and fear of pain [10]. On the other
hand, the painful experience at the time of dental
treatment has been stated as the main reason for
child uncooperative behavior [11]. Moreover, the
dental fear of parents and children with emotionally
negative temperament (crying, anger) [12]
and ashamed (inhibition, anguish) can also be
associated with the phenomenon [13].
Dental anxiety can be measured by self-
report instruments [7] Different measures,
presenting strengths and limitations [14], have
been developed over the years. The Children’s
Experiences of Dental Anxiety Measure (CEDAM)
was developed according to an established
cognitive behavioral clinical evaluation model [15]
to measure the negative cognitive e emotional
aspects of the preoccupation in children [7]. The use
of this instrument follows a holistic approach
that assesses how much the aforementioned
situations contribute to the onset and persistence
of anxiety [7,15].
The CEDAM has not been translated for
use in Brazil. This scale could support on the
determination of factors related to dental anxiety
in children, helping clinicians know the way to
control or reduce children’s dental anxiety [16].
Therefore, the study aimed to translate the
CEDAM to Brazilian Portuguese, and perform its
cultural adaptation for children.
MATERIAL & METHODS
The project was accepted by the Research
Ethics Committee of Federal University of Juiz de
Fora (Protocol No.: CAAE 55005421.7.0000.5147)
of the Federal University of Juiz de Fora, campus
Governador Valadares (UFJF-GV). The sample
was obtained from a public school, Escola
Estadual Coronel Camilo Soares, Ubá, MG,
Brazil. Parents and children signed the written
consent and assent, respectively. This study was
performed from October to November 2022.
The process of the translation and cultural
adaptation was previously authorized by the
authors of the original instrument. The CEDAM
is a self-report questionnaire of dental anxiety
experienced by children. The original English
instrument consists of 14 multiple-choice
items with response options ranging from 1 to
3 points [7]. The higher the score, the higher the
levels of dental anxiety.
Figure 1 shows the process of translation
and cultural adaptation [17-19].
Translation
The conceptual translation of the CEDAM
into Brazilian Portuguese was performed
independently by two Brazilian pediatric dentists
(C.S.O., R.A.S.S.R.), English teachers, who worked
independently (translated versions – T1, T2).
Back-translation
T1 and T2 were combined by the researchers,
and the document was back-translated to English
by two native English teachers (H.M., I.A.F.),
who worked independently (back-translated
versions – BT1, BT2). The accuracy of the English
translation based on the original instrument can
be veried in this moment.
Expert committee
The translations, back-translations and
original instrument were reviewed by a committee
composed by ve university professors in pediatric
dentistry area (A.R.F.C., M.A.B.P., M.B.D.G.,
R.A.S.S.R., T.S.B), one of whom also teach English
language (also participated as translator, T1) and
Psychology Applied to Dentistry (R.A.S.S.R.) and
one also graduated in the Program of Behavioral-
Multidisciplinary Medicine (expert in psychometric
analysis of health instruments) (T.S.B.). In this step,
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Translation and cultural adaptation of the Children’s Experiences of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
Santos JHL et al. Translation and cultural adaptation of the Children’s Experiences
of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
the semantic, idiomatic and cultural equivalences
were considered [19].
Cultural adaptation (pretest)
The rst translated version of the CEDAM
(V1) was pretest in 10 eight-to twelve-year-old
schoolchildren recruited from Escola Estadual
Coronel Camilo Soares, Ubá, MG, Brazil (10%
of the sample calculated for the main study of
validation and reliability, in process). The option
“I didn’t understand” was used to identify the
understandable questions. The questions of
CEDAM should not be misunderstood by more
than 15% of the respondents. Thus, the final
version (FV) was obtained.
RESULTS
Translation, back-translation and review by
the expert committee
A summary of suggestions by the Expert
Committee was shown on Table I. In the
translation process, both versions for some items
were identical or practically identical (T1=T2).
For other questions, one translation was preferred
over the other (T1≠T2), or the two translations
were united into a consensus version (T3), with
the objective of achieving good understanding
of the item.
The future tense was suggested by the Expert
Committee Review, as exemplied in Items 2 (“I
will say”) and 3 (“I will leave”), among others.
In the statement, the term “When” was removed
from the beginning of the sentence, keeping “Next
time”; and the expression “visit the dentist” was
replaced by “go to the dentist”. In Item 2, the
term “responsible” was preferred over “caregiver”
because it is better understood in the context
of Brazilian children. In Item 3, the expression
“Look inside my mouth” was replaced by “Look
at my mouth”, as it is more used by the evaluated
population. Finally, the rst translated version
was originated (V1).
Pre-test
The pretest was performed with
10 schoolchildren (♀=6). In applying V1, only
question 8 was misunderstood by one eight-
year-old female (10%). Therefore, the level of
understanding for all items was satisfactory
(higher than 85%), and the instrument was
considered socioculturally adapted. Table II shows
the Brazilian Portuguese version of the CEDAM.
DISCUSSION
The evaluated children had a good
understanding of the Brazilian CEDAM. The use
of scales to evaluate dental anxiety helps to
prevent unexpected behavior by anxious children
during dental care and to plan specic treatment
according to the emotional needs of each
patient [20].
The English study of original CEDAM
showed valid and reliable results in nine to
sixteen-year-old children with dental anxiety [7].
However, for use in other languages and cultures,
it is necessary to combine the literal translation
from one idiom to another and to adapt with
regards to colloquial language, and to cultural
characteristics of the target population [17].
To ensure the robustness of the methodology, it
Figure 1. Synopsis of the methodology.
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Translation and cultural adaptation of the Children’s Experiences of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
Santos JHL et al. Translation and cultural adaptation of the Children’s Experiences
of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
is necessary to follow and record each step of the
process in detail [17-19].
The use of only one translation requires
extreme skill and knowledge from the translator,
often resulting in low validity and reliability [21].
Moreover, if for one side, the literature recommends
professional translators [22], on the other hand,
translators with high sociocultural level may not
represent the overall population [17]. In the
same way, some authors recommend that the
translator has previous experience with health
questionnaires [23], and others that at least
one of the translators had technical knowledge
about the subject and the other not [17,19].
To obtain high-quality translation, this study used
two translators, pediatric dentistry specialists
(T1, T2) and two independent back-translators
(BT1, BT2). During these stages, the meaning
Table I - Summary of the suggestions of the Expert Committee
Versão original Translation The combined version
of T1 and T2 Backtranslation Eq. Committee
Item Sentence T1 T2 Synthesis BT1 BT2 V1
2R I will tell Eu vou dizer Eu vou dizer T1=T2 Eu vou dizer I will tell I’ll tell S Eu direi
2R Carers Cuidadores Responsáveis T1 Cuidadores Caregivers Caregivers C Responsáveis
3-5S When I
next visit
Quando eu
visitar ... na
próxima vez
Quando eu
visitar, da
próxima vez,
T1
Quando eu
visitar ... na
próxima vez
When I
visit ...
next time
Next time I
go to... CNa próxima vez
que eu for
3R I will let Eu vou deixar Eu vou deixar T1=T2 Eu vou deixar I will let I’ll let S Eu deixarei
3R In my
mouth
Dentro da
minha boca A minha boca T1 Dentro da
minha boca
Inside my
mouth
Inside my
mouth I A minha boca
3R I will try Eu vou tentar Eu vou tentar T1=T2 Eu vou tentar I will try I’ll try S Eu tentarei
3R I will not
let
Eu não vou
deixar
Eu não vou
deixar T1=T2 Eu não vou
deixar
I will not
let I’ll not let S Eu não deixarei
5R
They
would not
stop
Ele não pararia Eles não iam
parar T3 Eles não iriam
parar
They
wouldn’t
stop
They
wouldn’t
do so
SEles não
parariam
6-8S
When
I next
visit the
dentist, I
think
Quando eu
visitar o
dentista na
próxima vez eu
penso que
Quando eu
visitar, da
próxima vez,
o dentista, eu
acho
T3
Quando eu
visitar o
dentista na
próxima vez eu
acho que
When I
visit the
dentist
next time I
think
Next time
I go to the
dentist, I
think
C
Na próxima vez
que eu for ao
dentista, eu
acho que
6R I will not
be worried
Eu não ficarei
preocupado(a)
que
Eu não vou me
preocupar se T3
Eu não ficarei
preocupado(a)
se
I won’t be
worried if
I won’t be
worried
about
SEu não me
preocuparei se
6R
I will be
a little
worried
Eu ficarei
um pouco
preocupado(a)
que
Eu vou ficar
um pouco
preocupado(a)
se
T3
Eu ficarei
um pouco
preocupado(a)
se
I will be
a little
worried if
I’ll be a little
worried
about
S
Eu me
preocuparei um
pouco se
6R
I will
be very
worried
Eu ficarei muito
preocupado(a)
que
Eu vou
ficar muito
preocupado(a)
se
T3
Eu ficarei muito
preocupado(a)
se
I will
be very
worried if
I’ll be very
worried
about
S
Eu me
preocuparei
muito se
9-14S
When
I next
visit the
dentist, I
think I will
Quando eu
visitar o
dentista na
próxima vez
eu penso que
eu irei
Quando eu
visitar, da
próxima vez,
o dentista, eu
acho que vou
T3
Quando eu
visitar o
dentista na
próxima vez
eu acho que
eu irei
When I
visit the
dentist
next time I
think I will
Next time
I go to the
dentist, I
think I will
C
Na próxima vez
que eu for ao
dentista, eu
acho que
9-13R Not feel Não me sentir Não me sentir T1=T2 Não me sentir Not feel Not feel S Eu não me
sentirei
9-13R Feel Me sentir Sentir-me T1 Me sentir Feel Feel S Eu me sentirei
14R Feel that Sentir que Sentir que T1=T2 Sentir que Feel that Feel that S Eu sentirei que
14R I can only
trust
Eu posso
confiar apenas
Só posso
confiar T1 Eu posso
confiar apenas
I can only
trust
I can only
trust IEu posso confiar
somente
S, statement; R, response; T1, translation 1; T2, translation 2; BT1, back-translation 1; BT2, back-translation 2; V1, first translated version; Eq.,
equivalence; S, semantic; I, idiomatic; C, cultural.
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Translation and cultural adaptation of the Children’s Experiences of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
Santos JHL et al. Translation and cultural adaptation of the Children’s Experiences
of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
of the words was valued in order to better
express concepts or situations of the evaluated
population [17,24]. For example, the term
“look in my mouth” (Item 3) would be literally
translated to “look inside my mouth”, but the
term “look at my mouth” was chosen, as it is
considered a term of better understanding by
schoolchildren under study. In this line, the
original term “carers” (Item 2), which would
be translated to “caregivers”, was replaced by
“responsible”.
To minimize bias, the committee
organization must be cautious of commons views
among the members and a possible pressure
to form a consensus [21]. A multidisciplinary
committee must have one methodologist, a
health professional, a specialist in languages, all
translators and back-translators and the records
of the translation process so far [25]. The present
study used a heterogenous committee, with
members with similar experience in pediatric
dentistry, but with different expertise in
Psychology, Language and Psychometry areas.
Moreover, one of them also participated as
translator of the original questionnaire (T1).
Detecting and solving problems in the
earlier phases of the study is only possible by
redirecting the decisions in the process by the
expert committee [26]. It is noteworthy that, in
all changes, the maintenance of the same effect
and context intended by the original instrument
was prioritized.
The level of understanding of the first
translated version (V1) was tested in a small
number of the target population. Small errors
(grammar, typing, formatting) that still remain
at this stage also should be reviewed [23]. In the
present study, item 8 was misunderstood by one
eight-year-old female. This question asked about
self-control over what happens in the appointment.
Perhaps the concept of self-control can be a little
confusing for young children. Interesting aspect of
the cultural adaptation is the possibility of using
the technique of decentralization in the resolution
of discrepancies [17,22]. In decentralization, there
is an understanding that the process of cultural
adaptation is bilateral and that the difculty in
achieving equivalence in the target language can
be resolved by altering the original instrument
so that its new version is more easily translated/
adapted. In this study, considering that the
percentage of misunderstandings was less than
Table II. The Brazilian Portuguese version of CEDAM.
Medida de experiências de ansiedade odontológica em crianças
Item Respostas
1. Quando eu sei que eu
tenho uma consulta com
um dentista…
1. Eu não farei nada para evitar ir.
2. Eu farei algumas coisas para evitar ir.
3. Eu farei tudo para evitar ir.
2. Quando eu sei que eu
tenho uma consulta com
um dentista…
1. Eu direi aos meus pais/responsáveis que
eu não me importo de ir.
2. Eu direi aos meus pais/responsáveis que
eu preferiria não ir.
3. Eu direi aos meus pais/responsáveis que
eu realmente não quero ir.
3. Na próxima vez que eu
for ao dentista...
1. Eu deixarei o dentista olhar a minha boca.
2. Eu tentarei impedir um pouco o dentista
de olhar a minha boca.
3. Eu não deixarei o dentista olhar a minha
boca.
4. Na próxima vez que eu
for ao dentista...
1. Eu não me preocuparei se o dentista me
disser que eu preciso fazer algo.
2. Eu me preocuparei um pouco se o dentista
me disser que eu preciso fazer algo.
3. Eu realmente me preocuparei se o dentista
me disser que eu preciso fazer algo.
5. Na próxima vez que eu
for ao dentista...
1. Se eu pedisse ao dentista para parar
o que eles estavam fazendo, eles
definitivamente parariam.
2. Se eu pedisse ao dentista para parar o que
eles estavam fazendo, eles poderiam parar.
3. Se eu pedisse ao dentista para parar o que
eles estavam fazendo, eles não parariam.
6. Na próxima vez que eu
for ao dentista, eu acho
que...
1. Eu não me preocuparei se será doloroso.
2. Eu me preocuparei um pouco se será doloroso.
3. Eu me preocuparei muito se será doloroso.
7. Na próxima vez que eu
for ao dentista, eu acho
que...
1. Nada dará errado.
2. Alguma coisa dará um pouco errado.
3. Alguma coisa dará muito errado.
8. Na próxima vez que eu
for ao dentista, eu acho
que...
1. Eu terei muito controle sobre o que acontece
na consulta.
2. Eu terei um pouco de controle sobre o que
acontece na consulta.
3. Eu não terei nenhum controle sobre o que
acontece na consulta.
9. Na próxima vez que eu
for ao dentista, eu acho
que...
1. Eu não me sentirei trêmulo(a).
2. Eu me sentirei um pouco trêmulo(a).
3. Eu me sentirei muito trêmulo(a).
10. Na próxima vez que
eu for ao dentista, eu
acho que...
1. Eu não me sentirei estressado(a).
2. Eu me sentirei um pouco estressado(a).
3. Eu me sentirei muito estressado(a).
11. Na próxima vez que eu
for ao dentista, eu acho
que...
1. Eu não me sentirei chateado(a).
2. Eu me sentirei um pouco chateado(a).
3. Eu me sentirei muito chateado(a).
12. Na próxima vez que
eu for ao dentista, eu
acho que...
1. Eu não me sentirei envergonhado(a)
2. Eu me sentirei um pouco envergonhado(a).
3. Eu me sentirei muito envergonhado(a).
13. Na próxima vez que
eu for ao dentista, eu
acho que...
1. Eu não me sentirei bravo(a).
2. Eu me sentirei um pouco bravo(a).
3. Eu me sentirei muito bravo(a).
14. Na próxima vez que
eu for ao dentista, eu
acho que...
1. Eu sentirei que eu posso confiar
completamente no dentista.
2. Eu sentirei que eu posso confiar somente
um pouco no dentista.
3. Eu sentirei que eu não posso confiar no
dentista.
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Translation and cultural adaptation of the Children’s Experiences of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
Santos JHL et al. Translation and cultural adaptation of the Children’s Experiences
of Dental Anxiety Measure (CEDAM) to Brazilian Portuguese
15%, no reformulation was performed, and the
evaluated children showed good understanding
of the Brazilian CEDAM.
It is important to highlight that cultural
adaptation enables testing content and face
validity between the original scale and the
translated one, not guaranteeing, however,
the criterion validity and reliability of the
original instrument. For cultural adaptation to
be fully achieved, a study with an assessment
of the psychometric properties of the Brazilian
CEDAM in different contexts, such as pediatric
dentistry clinic, where children have had previous
experience with dental treatment. The validity
and reliability of the questionnaire should also
be tested in representative samples.
CONCLUSION
In conclusion, CEDAM was carefully
translated into Brazilian Portuguese and well-
understood by the evaluated population. Further
studies are need to test psychometric properties
of the questionnaire.
Acknowledgements
The authors wish to express their gratitude to
Prof. Jenny Porritt, Shefeld Hallam University,
for providing the original CEDAM and thank all
children who participated as volunteers in the
survey. The authors thank R.A.S.S.R., H.M. e
I.A.F. who participated as translators and back-
translators of the questionnaire.
Author’s Contributions
JHLS: Conceptualization, Methodology, Data
Curating, Writing – Original Draft Preparation.
MBDG: Methodology, Writing – Review &
Editing. CSO: Methodology, Writing – Review &
Editing. MABP: Methodology, Writing – Review
& Editing ARFC: Methodology, Writing – Review
& Editing. TSB: Conceptualization, Methodology,
Data Curating, Writing – Review & Editing,
Supervision.
Conict of Interest
The authors of the manuscript declare that
there are no conicts of interest.
Funding
The authors thank the nancial support of
Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior (CAPES), Brazil.
Regulatory Statement
This study was conducted in accordance with
all the provisions of the local human subjects
oversight committee guidelines and policies of:
Research Ethics Committee of Federal University
of Juiz de Fora. This study protocol was reviewed
and approved by [Research Ethics Committee
of Federal University of Juiz de Fora], approval
number [CAAE 55005421.7.0000.5147].
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Taís de Souza Barbosa
(Corresponding address)
Universidade Estadual Paulista, Instituto de Ciência e Tecnologia,
Departamento de Odontologia Social e Clínica Infantil, São José dos Campos,
SP, Brazil.
Email: tais.barbosa@unesp.br Date submitted: 2023 Dec 04
Accept submission: 2024 Feb 16
