Dental fear in children: clinical consequences. Suggested behaviour management strategies in treating children with dental fear

Evaluation of the relationship between dental anxiety and oral health status of mothers and their children

BACKGROUND

Mothers usually have the primary role in raising children and developing health-related behaviors. This study aims to evaluate the relationship between dental anxiety and oral hygiene status of mothers and children's dental anxiety and gingival health.

METHODS

The study included 305 children, aged 4-12 years, who came to the dentist for the first time and their mothers. All the demographic and oral hygiene information were collected through a questionnaire. The dental anxiety of the mothers and children was assessed using the Modified Dental Anxiety Scale (MDAS) and Venham Picture Test (VPT), respectively. The oral examination of the mother and children was performed, and their PI, GI, and DMFT scores were recorded.

RESULTS

While the correlation between MDAS and VPT was positive and strong in children aged 8-12, it was positive but weak in the 4-7 age group. A significant relationship was detected between the mother's PI, GI, DMFT, and the child's VPT score. According to the mothers' dental anxiety, there were no statistically significant differences in PI, GI, and dmft values in children aged between 4 to 7. A moderately positive and statistically significant relationship between maternal dental anxiety and children's DMFT was identified in children aged 8-12.

CONCLUSIONS

Children's dental anxiety was significantly influenced by maternal dental anxiety, post-treatment complications experienced by the mother, and the oral health status of the mother.

TRIAL REGISTRATION

Clinical Trials-ID: NCT05563532; Registration Date: 17.09.2022.

Behavior and anxiety levels in pediatric patient: The behavioral changes and anxiety of pediatric patient in dental clinic

AIM

The aim of this study is to evaluate the behavioral patterns and anxiety levels of pediatric patients in dental clinics, discern their behavioral expectations, and investigate the associations between these factors and the patient's age and gender.

METHODS

In this cross-sectional study, 150 pediatric patients visiting Sharjah Thumbay Dental Hospital for treatment were recruited over a study period of 23 weeks (February 12, 2022 to July 23, 2022). The patient's age ranged from 2 to 14 years. Guardians were informed about the study and their written consent was taken.

EXCLUSION CRITERIA

Children over 14 years old, children whose guardians refused to participate in the study, and medically compromised children. Frankl's behavior rating scale, Categorical rating scale, and Venham anxiety and behavioral rating scales were used to evaluate the pediatric patient's behavior and anxiety at the end of the dental visit, the evaluation was done by the same trained dental student for all the patients.

RESULTS

When the Mann-Whitney U test was used for gender, no significant differences were observed in behavior and anxiety between male and female patients across all scales employed in this study. Conversely, when examining various age groups for behavior and anxiety using the Kruskal-Wallis test, significant findings emerged across nearly all scales. In the categorical rating scale, the age group of 11-14 years exhibited the most notable results in subscales of crying (p = .034), cooperativeness (p = .002), and apprehensiveness (p = .003).

CONCLUSION

The pediatric patients who took part in this study exhibited heightened anxiety when attending dental clinics. This study underscores the importance of understanding child behavior and utilizing effective communication with children and their guardians. Dental professionals should consider implementing strategies to manage child behavior during visits. Further research is required to develop sufficient strategies tailored to different pediatric populations, aiming to enhance dental care outcomes for pediatric patients.

Exploring Preschoolers' Emotions in Pediatric Dentistry

OBJECTIVE

 Emotion is a feeling that someone can feel. Emotions are generally shown through behavior or facial expressions. Emotions are essential for dental treatment because there is a relation between the emotions felt by children and the success of the dental treatment that the dentist will give. This study aimed to describe variables of emotions about dental treatment.

MATERIALS AND METHODS

 Descriptive analysis using a convenience nonrandom sampling technique was conducted on 58 preschool children aged 3 to 6 years old who came for dental treatment at the Bandung Dental Center in Bandung, Indonesia. The instrument used to ask children how they feel about dental care is a 7-item questionnaire derived from the children's fear survey scale-dental subscale. Meanwhile, the media used by children to respond was a card with facial expressions from the Facial Expression Emotion Scale.

RESULTS

 The results showed that only participants aged 4 responded with one type of emotion (happy), while the other age groups gave various emotional responses. Fear emotion began to appear in the age group of 5 and 6 years and only in girls, while emotions of anger also appeared in girls and only at the age of 5.

CONCLUSION

 In this study, the emotions that children choose about dental care at the Bandung Dental Center clinic are happy emotions. The emotions of fear and sadness were chosen more by girl participants, while none of the boy participants chose the emotion of fear. This sad and fearful response is associated with invasive dental treatment. Anger was chosen as a child's response dominantly because of the parents' invitation to the dentist.

A grounded theory study on Swedish 10 to 16-year-olds' perceptions of pain in conjunction with orthodontically indicated tooth extraction

OBJECTIVE

Children frequently experience pain and/or discomfort during dental treatment. Still, pain research in dentistry has mainly been performed on adults using quantitative methods while research on the child's perspective is scarce. This study aims to explore and describe children's experiences and/or thoughts regarding pain in conjunction with tooth extraction.

MATERIAL AND METHODS

Interviews were carried out with twelve Swedish 10-16-year-olds who had recently undergone tooth extractions due to orthodontic reasons. Interviews were transcribed verbatim and analysed according to grounded theory.

RESULTS

A core category was identified and named 'handling the unavoidable unknown'. The informants recalled experiences of pain and discomfort during extractions. However, instead of focussing on pain, they described an urge for more information about the procedure and what to expect in terms of pain and/or discomfort, during and/or after treatment. They stated that the levels of pain/discomfort were manageable, while the lack of information negatively affected their coping abilities, causing feelings of unease.

CONCLUSIONS

To improve patients' ability to deal with pain in conjunction with dental extraction, the dental team should ensure better and individually tailored information about the treatment. Thus, the use of psychological techniques is a cornerstone in pain management and must be reflected in clinical guidelines.

The CALM trial protocol: a randomised controlled trial of a guided self-help cognitive behavioural therapy intervention to reduce dental anxiety in children

BACKGROUND

Globally, around 13% of children experience dental anxiety (DA). This group of patients frequently miss dental appointments, have greater reliance on treatment under general anaesthesia (GA) and have poorer oral health-related quality of life (OHRQoL) than their non-dentally anxious peers. Recently, a low-intensity cognitive behavioural therapy (CBT)-based, self-help approach has been recommended for management of childhood anxiety disorders. A feasibility study conducted in secondary care found this guided self-help CBT resource reduced DA and a randomised controlled trial was recommended. The present study aims to establish the clinical and cost-effectiveness of a guided self-help CBT intervention to reduce DA in children attending primary dental care sites compared to usual care.

METHODS

This 4-year randomised controlled trial will involve 600 children (aged 9-16 years) and their parent/carers in 30 UK primary dental care sites. At least two dental professionals will participate in each site. They will be assigned, using random allocation, to receive the CBT training and deliver the intervention or to deliver usual care. Children with DA attending these sites, in need of treatment, will be randomly allocated to be treated either by the intervention (CBT) or control (usual care) dental professional. Children will complete questionnaires relating to DA, OHRQoL and HRQoL before treatment, immediately after treatment completion and 12 months post-randomisation. Attendance, need for sedation/GA and costs of the two different approaches will be compared. The primary outcome, DA, will be measured using the Modified Child Dental Anxiety Scale. Scores will be compared between groups using a linear mixed model.

DISCUSSION

Treating dentally anxious patients can be challenging and costly. Consequently, these children are frequently referred to specialist services for pharmacological interventions. Longer waiting times and greater travel distances may then compound existing healthcare inequalities. This research will investigate whether the intervention has the potential to reduce DA and improve oral health outcomes in children over their life-course, as well as upskilling primary dental healthcare professionals to better manage this patient group.

TRIAL REGISTRATION

This clinical trial has been registered with an international registry and has been allocated an International Standard Randomised Controlled Trial Number (ISRCTN27579420).

Children's Perceptions of Dental Experiences and Ways to Improve Them

This qualitative study explored children's perceptions of their dental experiences and their acceptability of the CARD™ (Comfort, Ask, Relax, Distract) system, adapted for the dental setting as a means to mitigate dental fear and anxiety (DFA). A purposive sample of 12 participants (7 males) aged 8-12 years receiving dental care at the Paediatric Dental Clinic, University of Toronto, was recruited. Virtual one-on-one interviews were augmented with visual aids. Participants were oriented to and asked about their perceptions of various dental procedures. Data were deductively analyzed, according to the Person-Centered Care framework (PCC). Four themes were identified: establishing a therapeutic relationship, shared power and responsibility, getting to know the person and empowering the person. Children emphasized the importance of clinic staff attributes and communication skills. They expressed a desire to engage more actively in their own care and highlighted the positive influence of pre-operative education and preparation. Participants found the CARD™ system to facilitate opportunities for self-advocacy in their dental care.

Behavioral and neural mechanisms of latent inhibition

Fear is an adaptive emotion that serves to protect an organism against potential dangers. It is often studied using classical conditioning paradigms where a conditioned stimulus is paired with an aversive unconditioned stimulus to induce a threat response. Less commonly studied is a phenomenon that is related to this form of conditioning, known as latent inhibition. Latent inhibition (LI) is a paradigm in which a neutral cue is repeatedly presented in the absence of any aversive associations. Subsequent pairing of this pre-exposed cue with an aversive stimulus typically leads to reduced expression of a conditioned fear/threat response. In this article, we review some of the theoretical basis for LI and its behavioral and neural mechanisms. We compare and contrast LI and fear/threat extinction-a process in which a previously conditioned cue is repeatedly presented in the absence of aversive outcomes. We end with highlighting the potential clinical utility of LI. Particularly, we focus on how LI application could be useful for enhancing resilience, especially for individuals who are more prone to continuous exposure to trauma and stressful environments, such as healthcare workers and first responders. The knowledge to be gained from advancing our understanding of neural mechanisms in latent inhibition could be applicable across psychiatric disorders characterized by exaggerated fear responses and impaired emotion regulation.

Does Dental Fear in Children Predict Untreated Dental Caries? An Analytical Cross-Sectional Study

Despite free health care services in Saudi Arabia, the prevalence of caries in children is substantially greater in comparison to other high-income countries. Dental fear in children may be an important issue that needs attention. Therefore, the aim was to investigate the role of dental fear in predicting untreated dental caries in schoolchildren. This analytical cross-sectional study included children aged 8–10 years residing in Saudi Arabia. Dental status via oral examinations was surveyed with the WHO standardized chart and the Children Fear Survey Schedule—Dental Subscale was used to score dental fear. Descriptive, binary, and multivariable logistic regression analyses were performed to report the findings at 5% statistical significance. Overall, there were 798 schoolchildren with an average fear score of 36. Nearly 70.4% reported fear of someone examining their mouth. About 76.9% had at least one carious tooth in their oral cavity. Children with dental fear were 1.8 times (OR = 1.80; 95% CI = 1.26, 2.56) more likely to have at least one untreated carious tooth in their oral cavity than those who did not express fear during oral examinations and dental procedures. Thus, the current study concludes that fear of dentists and dental treatment procedures successfully predicts untreated carious teeth in schoolchildren.

Effectiveness of topical haemocoagulase as a haemostatic agent in children undergoing extraction of primary teeth: a split-mouth, randomised, double-blind, clinical trial

AIM

To assess the effectiveness of topically-administered haemocoagulase (batroxobin) (HC) following dental extractions in children.

DESIGN

Split-mouth design, where either HC (test) or Normal Saline (control) (NS) was administered to children (5-9 years) requiring bilateral extractions of primary molars. Participants were randomised to (i) extraction sequence; (ii) test-solution administered thereafter.

OUTCOME MEASURE

time taken (in seconds) for complete cessation of bleeding.

RESULTS

Thirty participants completed the trial receiving HS (n = 30) and NS (n = 30). No adverse events were reported. Time to bleeding cessation was lower in HS group (82.5 ± 13.99 s) than NS group (240.5 ± 54.34 s). Difference between groups (paired t test) was statistically very highly significant (P = 0.000).

CONCLUSION

Topical HC produced significant reductions in time for haemostasis and was clinically effective in controlling haemorrhage from extraction wounds in children. HC may be favourably utilised by paediatric dentists, especially with pre-cooperative or special-healthcare-needs patients, improving patient care.

Non‐pharmacological interventions for managing dental anxiety in children

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

This review aims to assess the effectiveness of non‐pharmacological interventions for reducing dental anxiety in children.

Objective assessment of the influence of the parental presence on the fear and behavior of anxious children during their first restorative dental visit

Aims and Objectives:

Parents play an important role in the dental behavior of a child patient. This study aimed to assess the effect of parental presence on the behavior of the child and objectively measure the behavior using pulse oximetry.

Materials and Methods:

The study was registered with the clinical trials registry of the National Institutes of Health (NCT02619981). The children were divided into three groups, those who had no accompanying parent, those accompanied by their fathers, and those accompanied by their mothers. The Venham anxiety and behavior scores were used for subjective measurements whereas the objective measurement of fear was done by measuring the heart rate using a portable pulse oximeter at six critical clinical situations. Statistical analysis was carried out using the Statistical Package for the Social Sciences version 21 (IBM corp. Armonk, NY, USA).

Results:

One hundred and twenty two children aged between 6 years and 8 years completed the study. Most of the children accompanied by fathers were males while most of the children accompanied by their mother were females. It was seen that females showed a higher mean heart rate than males at all steps. Children who had their parents outside the operatory exhibited lower anxiety and behavior scores than those whose parents were present; however, they showed a significantly higher pulse rate at all procedures. Boys had higher anxiety and behavior scores than girls, however, these differences were not statistically significant.

Conclusion:

The results of this study suggest that the presence of the parent in the operatory reduces the physiological manifestations of anxiety in children in their first restorative dental visit.

Reliability and validity of the Children's Fear Survey Schedule-Dental Subscale for Arabic-speaking children: a cross-sectional study

Background

Early recognition of dental fear is essential for the effective delivery of dental care. This study aimed to test the reliability and validity of the Arabic version of the Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS).

Methods

A school-based sample of 1546 children was randomly recruited. The Arabic version of the CFSS-DS was completed by children during class time. The scale was tested for internal consistency and test-retest reliability. To test criterion validity, children’s behavior was assessed using the Frankl scale during dental examination, and results were compared with children’s CFSS-DS scores. To test the scale’s construct validity, scores on “fear of going to the dentist soon” were correlated with CFSS-DS scores. Factor analysis was also used.

Results

The Arabic version of the CFSS-DS showed high reliability regarding both test-retest reliability (intraclass correlation = 0.83, p < 0.001) and internal consistency (Cronbach’s α = 0.88). It showed good criterion validity: children with negative behavior had significantly higher fear scores (t = 13.67, p < 0.001). It also showed moderate construct validity (Spearman’s rho correlation, r = 0.53, p < 0.001). Factor analysis identified the following factors: “fear of invasive dental procedures,” “fear of less invasive dental procedures” and “fear of strangers.”

Conclusion

The Arabic version of the CFSS-DS is a reliable and valid measure of dental fear in Arabic-speaking children. Pediatric dentists and researchers may use this validated version of the CFSS-DS to measure dental fear in Arabic-speaking children.

Masking the bitter taste of injectable lidocaine HCl formulation for dental procedures

Several attempts have been made to mask the bitter taste of oral formulations, but none have been made for injectable formulations. This study aims to mask the bitter taste of dental lidocaine HCl (LID) injection using hydroxypropyl-β-cyclodextrin (HP-β-CD) and sodium saccharin. Inclusion complexes of LID and HP-β-CD were prepared by the solution method in 1:1 and 1:2 M ratios. Inclusion complexes in solution were studied using phase solubility in phosphate buffer solutions (pH 8, 9, and 10). Freeze-dried inclusion complexes were characterized using differential scanning calorimetry (DSC), X-ray, Fourier transform infrared (FT-IR), nuclear magnetic resonance (NMR), scanning electron microscopy (SEM), and in vitro release. Injectable formulations were prepared using inclusion complexes and characterized for stability and for taste using an Alpha MOS ASTREE electronic tongue (ETongue). The association constants of HP-β-CD with lidocaine-free base and its ionized form were found to be 26.23 ± 0.00025 and 0.8694 ± 0.00045 M(-1), respectively. Characterization studies confirmed the formation of stable inclusion complexes of LID and HP-β-CD. Injectable formulations were found to be stable for up to 6 months at 4°C, 25°C, and 40°C. The taste evaluation study indicated that HP-β-CD (1:1 and 1:2 M ratios) significantly improved the bitter taste of LID injectable formulation. In conclusion, inclusion complex in the 1:1 M ratio with 0.09% sodium saccharin was considered to be optimum in masking the bitter taste of LID.

Dental fear and anxiety in children and adolescents: qualitative study using YouTube

Background

Dental fear and anxiety (DFA) refers to the fear of and anxiety towards going to the dentist. It exists in a considerable proportion of children and adolescents and is a major dilemma in pediatric dental practice. As an Internet social medium with increasing popularity, the video-sharing website YouTube offers a useful data source for understanding health behaviors and perceptions of the public.

Objective

Using YouTube as a platform, this qualitative study aimed to examine the manifestations, impacts, and origins of DFA in children and adolescents from the public’s perspective.

Methods

To retrieve relevant information, we searched YouTube using the keywords “dental fear”, “dental anxiety”, and “dental phobia”. Videos in English expressing a layperson’s views or experience on children’s or adolescent’s DFA were selected for this study. A video was excluded if it had poor audiovisual quality, was irrelevant, was pure advertisement or entertainment, or contained only the views of professionals. After the screen, we transcribed 27 videos involving 32 children and adolescents, which were reviewed by a panel of 3 investigators, including a layperson with no formal dental training. Inductive thematic analysis was applied for coding and interpreting the data.

Results

The videos revealed multiple manifestations and impacts of DFA, including immediate physical reactions (eg, crying, screaming, and shivering), psychological responses (eg, worry, upset, panic, helplessness, insecurity, resentment, and hatred), and uncooperativeness in dental treatment. Testimonials from children, adolescents, and their parents suggested diverse origins of DFA, namely personal experience (eg, irregular dental visits and influence of parents or peers), dentists and dental auxiliaries (eg, bad manner, lack of clinical skills, and improper work ethic), dental settings (eg, dental chair and sounds), and dental procedures (eg, injections, pain, discomfort, and aesthetic concerns).

Conclusions

This qualitative study suggests that DFA in children and adolescents has multifaceted manifestations, impacts, and origins, some of which only became apparent when using Internet social media. Our findings support the value of infodemiological studies using Internet social media to gain a better understanding of health issues.

Understanding children's dental anxiety and psychological approaches to its reduction

BACKGROUND

Dental anxiety is a common problem, which can affect people of all ages, but appears to develop mostly in childhood and adolescence. Childhood dental anxiety is not only distressing for the child and their family but is also associated with poor oral health outcomes and an increased reliance on costly specialist dental services.

AIM

This article will consider the prevalence, development, and implications of children's dental anxiety. It will also discuss the opportunities for and challenges of psychological approaches such as cognitive behavioural therapy aimed at the reduction of dental anxiety in children.

Dental Fear in Children with a Cleft Lip and/or Cleft Palate

Objective

To assess the level of dental fear in children with a cleft lip and/or palate, to compare this level with that of a normative group testing the hypothesis that children with a cleft lip and/or palate have a higher level of dental anxiety than children from the general population, and to assess the relation between dental fear and coping.

Design

Cross-sectional study.

Setting

VU Medical Centre University Amsterdam.

Patients

A total of 110 children (4 to 12 years old, 50 girls) with a cleft lip and/or palate.

Interventions

Dental fear in the study group was compared with a normative group of Dutch children.

Main Outcome Measures

Dental fear was investigated using the parental version of the dental subscale of the Children's Fear Survey Schedule for children aged 4 and 5 years old (n = 36). Also the Inventory of Stressful Situations was completed. Children aged 6 to 12 years old also completed the Dental Cope Questionnaire.

Results

Young children with a cleft lip and/or palate experience more dental fear compared with children in a normative control group (Children's Fear Survey Schedule dental subscale scores: 30.3 ± 14.6 compared with 24.6 ± 8.6, p < .01). A weak correlation was found between the child's dental anxiety (Children's Fear Survey Schedule dental subscale) and his or her coping behavior (Dental Coping Questionnaire) ( r = .196 p < .05). A clear correlation exists between the total Inventory of Stressful Situations and total Children's Fear Survey Schedule scores of the youngest age group ( r = .507 p < .01).

Conclusions

Findings support the hypothesis that dental anxiety is related to a higher level of exposure to medical interventions at a young age.

Differences in the perception of seven behaviour-modifying techniques in paediatric dentistry by undergraduate students using lecturing and video sequences for teaching

Whilst preparing undergraduate students for a clinical course in paediatric dentistry, four consecutive classes (n = 107) were divided into two groups. Seven behaviour-modifying techniques were introduced: systematic desensitization, operant conditioning, modelling, Tell, Show, Do-principle, substitution, change of roles and the active involvement of the patient. The behaviour-modifying techniques that had been taught to group one (n = 57) through lecturing were taught to group two (n = 50) through video sequences and vice versa in the following semester. Immediately after the presentations, students were asked by means of a questionnaire about their perceptions of ease of using the different techniques and their intention for clinical application of each technique. After completion of the clinical course, they were asked about which behaviour-modifying techniques they had actually used when dealing with patients. Concerning the perception of ease of using the different techniques, there were considerable differences for six of the seven techniques (P < 0.05). Whilst some techniques seemed more difficult to apply clinically after lecturing, others seemed more difficult after video-based teaching. Concerning the intention for clinical application and the actual clinical application, there were higher percentages for all techniques taught after video-based teaching. However, the differences were significant only for two techniques in each case (P < 0.05). It is concluded that the use of video based teaching enhances the intention for application and the actual clinical application only for a limited number of behaviour-modifying techniques.

An evaluation of the PALS after treatment modelling intervention to reduce dental anxiety in child dental patients

AIM

The aim of this study was to assess the effectiveness of the passivity to activity through live symbolic (PALS) after treatment modelling intervention to reduce child dental anxiety.

METHODS

A convenience sample of consecutive 5- to 10-year-old dental patients were randomly assigned to intervention or control groups. Self-reported child dental anxiety was assessed at the start of each visit. At the end of each visit, children in the intervention group were introduced to a glove puppet, which acted as the PALS model. The intervention group children re-enacted the treatment they had just received on the puppet's teeth. At the end of each visit, the control children received motivational rewards only. The change in dental anxiety scores was examined by t-tests and analysis of covariance.

RESULTS

The final analysis included 27 intervention children and 26 control children. For the intervention group, there were no statistically significant changes in dental anxiety over a course of treatment, between first and second preventive visits, between first and second invasive treatment visits, or between first attendance and subsequent recall attendance. For the control group, a statistically significant decrease in dental anxiety was observed between the first and second invasive dental treatment visits.

CONCLUSION

The PALS after treatment modelling intervention was ineffective in reducing child dental anxiety.