A study on the influence of dominant sound sources on users' emotional perception in a pediatric dentistry clinic

Introduction

Soundscape in dental clinics has varying degrees of impact on the emotions of healthcare workers and young patients. Emotions such as restlessness, anxiety, anger, and nervousness are commonly found among dental healthcare workers. Pediatric dental clinics are an important part of dental clinics, but there is a lack of research on the soundscape within pediatric dental clinics.

Methods

This study focuses on a typical pediatric dental clinic, using a combination of field questionnaires and objective measurements. It aims to determine the impact of dominant sound sources on the emotional perception (nervousness, restlessness, anger, fear, pain) and hostile emotional responses of users in the pediatric dental clinic.

Results

In the soundscape of pediatric dental clinics for young pediatric patients, users experience negative emotional perceptions (nervousness, restlessness, anxiety, anger, fear, and pain) and emotional responses of hostility. The dominant sound sources can be divided into two categories: dental (dental drill, air-water syringe, and saliva ejector) and nondental (children crying). Under the influence of dental dominant sound sources, there was a significant negative correlation between the emotional perceptions of healthcare workers and their negative emotional perceptions (p  <  0.05). Conversely, for young pediatric patients aged 0-11  years, a significant positive correlation was observed between their emotional perceptions and negative emotional perceptions. The mean perceived degrees of nervousness and fear in young pediatric patients were 1.82 and 1.71 times stronger, respectively, than those observed in healthcare workers. Under the influence of non-dental dominant sound sources, the average degree of emotional perception among healthcare workers was 0.71 higher than that of young pediatric patients, and anxiety perception was significantly enhanced (p  <  0.05). The mean degree of nervousness perception was 1 point higher in healthcare workers compared to young pediatric patients, restlessness perception was 1.1 stronger, and there was a presence of mild pain perception. In terms of demographic/social factors, age, occupation, and years of work significantly affected the perceptions of fear and restlessness among healthcare workers, while age had a significant impact on the emotional reaction of hostility in young pediatric patients.

Discussion

The results of this study indicate that the soundscape is an important factor in creating a comfortable treatment environment in pediatric dental clinics. Healthcare workers and young pediatric patients are significantly affected by the dominant sound sources in the clinic, and these effects are closely related to demographic and social factors such as age, profession, and years of experience. This finding can provide more targeted methods and strategies for the design and creation of soundscapes in dental clinics.

The Abeer Children Dental Anxiety Scale (ACDAS) cross-cultural adaptation and validity of self-report measures in the Malaysian Children Context (MY-ACDAS)

BACKGROUND

The Abeer Children Dental Anxiety Scale (ACDAS) source language was developed and validated in an English-speaking country in the UK to measure dental anxiety among children. The ACDAS also included the child's cognitive assessment, as well as feedback from the parent or the legal guardian and a dental health professional (DHP). This is the first study to validate the application of the ACDAS in Malay or Bahasa Melayu for children aged 6-16 years.

AIM

To assess the Malay-translated version of the ACDAS, postadaptation into the local context and validation by the content and construct experts.

DESIGN

The English ACDAS was translated into Malay first through forward translation and then through backward translation. The prefinal translated version of the instrument was designed, with the participation of 61 children and 61 parents or legal guardians. Subsequently, a final cross-cultural adaptation of the instrument was then made for another group of participants and evaluated for validity and test-retest reliability among 144 children and 144 parents or legal guardians participating in the self-report feedback process at the Paediatric Dental Clinic, Faculty of Dentistry, Universiti Malaya, Kuala Lumpur, Malaysia. The cross-cultural adaptation of the instrument considered translating to Malaysian national language and adapting to its culture.

RESULTS

The Malay-translated ACDAS consisted of 19 items. The translated version of Malaysian-ACDAS (MY-ACDAS) achieved an acceptable agreement between six expert committee members with an internal consistency (Cronbach's alpha value, αconsistency) of 0.839. The test-retest reliability results of all participants support semantic and conceptual equivalence as an accepted construct validity between the children, parents and DHPs across the multicultural Malaysian population.

CONCLUSION

The MY-ACDAS is a valid and reliable scale for measuring dental anxiety among Malaysian children.

Development and validation of the Iranian version of the Children's Experiences of Dental Anxiety Measure (CEDAM)

OBJECTIVE

The aim of this study was to develop the Iranian version of the Children's Experiences of Dental Anxiety Measure (CEDAM) and evaluate its validity and reliability in assessing dental anxiety in children aged 9-16.

METHODS

The CEDAM was translated into Persian following the guidelines of the IQOLA project. A ‎sample of children completed the measure in a clinical setting, with a subgroup completing it ‎again to assess test-retest reliability. Concurrent criterion validity was evaluated by having all ‎participants complete the Modified Child Dental Anxiety Scale (MCDAS) alongside the ‎CEDAM. Construct validity was examined using exploratory and confirmatory factor ‎analyses.‎ RESULTS: The study included 275 children between the ages of 9 and 16. The Iranian version of CEDAM ‎exhibited excellent internal consistency with a Cronbach's ⍺ coefficient of 0.83. Test-retest ‎reliability was also high, with an intraclass correlation coefficient value of 0.96. Furthermore, there was a significant and ‎positive correlation between CEDAM and MCDAS scores (ρ = 0.72, p < .01). Exploratory ‎factor analysis identified two factors, and confirmatory factor analysis confirmed that the ‎instrument aligned well with the factor structure obtained from the exploratory analysis.‎ CONCLUSION: This study provides evidence supporting the validity and reliability of the Iranian version of ‎CEDAM as a valuable tool for evaluating dental anxiety in Persian-speaking children between ‎the ages of 9 and 16.‎.

Assessment of Dental Anxiety in Children: Reliability and Validity of the Questionnaire to Assess Dental Anxiety in Children (QADA-C)

This study presents a measure to assess dental anxiety in children. To gain a better understanding of children's fear and anxiety in the dental setting, instruments to gather data with high quality are necessary and missing, especially in the German language. Based upon the facet approach, the Questionnaire to Assess Dental Anxiety in Children (QADA-C) includes items concerning anxiety reactions in thinking, behavior, and feelings in the form of short statements. The item formulation was adapted for children of the target age (9-11 years), and items were presented with pictures of dental situations. Item and reliability analyses in a sample of 1019 children showed the good quality of the instrument (Cronbach's alpha = 0.89), and the validity indicators revealed its ability to differentiate high-anxiety, low-anxiety, and non-anxious children with an overall sum score. This score was proven to correlate with oral health criteria (decayed/missing/filled teeth, oral health behavior, oral health knowledge). Its easy administration and appropriateness for children make the questionnaire applicable in the dental office for clinical purposes as well as in research contexts.

Predictors of Intra-Operative and Post-Operative Pain Associated with Routine Dental Procedures in Children: A Systematic Review and Meta-Analysis

Background: Understanding predictors of pain associated with paediatric dental procedures could play an important role in preventing loss of cooperation, which often leads to the procedure having to be performed under general anaesthesia. Aim: We aimed to identify predictors of intra-operative and post-operative pain associated with routine dental procedures in children. Materials and Methods: A systematic review of observational studies was performed using electronic searches on MEDLINE, EMBASE, PsycINFO, Global Health via OVID, PubMed, Scopus, and SciELO. The NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to evaluate the quality of the included studies, which were meta-analysed to estimate the impact of dental procedures and anxiety on children's pain perception. A meta-regression analysis was also performed to determine the relative effect of predictors on children's pain perception measured as mean differences on a visual analogue scale (VAS). Results: The search identified 532 articles; 53 were retrieved for full-text screening; 6 studies were included in the review; and 4 were eligible for the meta-analysis. The meta-analysis showed the types of procedures that predicted intra-operative pain, with dental extractions being the most painful (Mean VAS Difference [MD] 46.51 mm, 95% confidence interval [CI] 40.40 to 52.62 mm). The meta-regression showed that pain scores for dental extractions were significantly higher than polishing (the least painful procedure (reference category)) by VAS MD = 23.80 mm (95% CI 5.13-42.46 mm, p-value = 0.012). It also showed that highly anxious children reported significantly higher pain scores during dental procedures by a 12.31 mm MD VAS score (95% CI 5.23-19.40 mm, p-value = 0.001) compared to those with low anxiety levels. Conclusions: This systematic review demonstrates that the strongest predictors of intra-operative pain associated with paediatric dental procedures are dental extractions followed by drilling. Children with high anxiety also reported more pain for similar procedures. Tailoring interventions to reduce pain associated with paediatric dental procedures should be a priority for future research, as reducing pain can impact compliance and could reduce the need for general anaesthesia in dental treatment.

Evaluation of the Erbium-doped Yttrium Aluminum Garnet Laser and the Conventional Method on Pain Perception and Anxiety Level in Children during Caries Removal: A Randomized Split-mouth Study

Aim and objective

To assess and compare children's anxiety level and pain perception during cavity preparation using an erbium-doped yttrium aluminum garnet (Er:YAG) laser vs traditional rotational treatment.

Materials and methods

A randomized, controlled, split-mouth clinical trial was carried out in 35 healthy children with 70 carious primary molars. Teeth were divided equally into two groups according to the method of treatment. A bur was used to prepare the cavity in one quadrant, while an Er:YAG laser was used to prepare the cavity in the other quadrant. Anxiety was assessed using Venham's dental anxiety scale and a fingertip pulse oximeter. The pain was assessed using the Wong-Baker Face Pain Rating Scale, and the number of local anesthesia (LA) needed during both procedures was also considered.

Results

The mean age was 9.4 ± 1.29. Males accounted for 51.4% of the participants. There were no statistically significant variations in pulse rate at the baseline between Er:YAG laser and the conventional treatments. The mean pulse rate was higher during the conventional intervention than during the laser intervention; this difference was statistically significant vs the baseline pulse rate. The mean pulse rate with the conventional method was significantly higher during and after cavity formation than with the laser method. The Er:YAG laser and the conventional groups showed statistically significant differences in the Venham's and Wong-Baker scores. The scores of both scales were much higher in the conventional group. The number of participants who requested LA during the conventional technique was significantly higher than during the laser procedure.

Conclusion

Using Er:YAG lasers to remove caries produces minimal pain and anxiety and reduces the requirement for LA.

Clinical significance

During cavity preparation, the Er:YAG laser helps children stay calm.

How to cite this article

Abdrabuh RE, El Meligy OAES, Felemban OM, et al. Evaluation of the Erbium-doped Yttrium Aluminum Garnet Laser and the Conventional Method on Pain Perception and Anxiety Level in Children during Caries Removal: A Randomized Split-mouth Study. Int J Clin Pediatr Dent 2023;16(S-1):S39-S44.

Pre-Treatment and Post-Treatment Dental Anxiety in Patients Visiting Intern Dental Clinic

Background and Objectives: This study aimed to assess the dental anxiety of patients using the modified dental anxiety scale (MDAS) questionnaire along with examining the possible relationship between dental anxiety and sociodemographic factors. Materials and Methods: The MDAS questionnaire was used to assess the anxiety level of the patients which included a total of five questions and five options to respond to each question. MDAS questionnaire was filled out by all the patients before the dental treatment. After finishing the treatment, all the patients were given a post-treatment questionnaire to assess their anxiety levels after treatment. Descriptive statistics were performed for measuring the frequency of responses. Mann-Whitney U test was used to compare the anxiety between the gender. The chi-square test was used to identify the distribution of pre-treatment with gender and post-treatment questionnaire with gender and treatment modalities. Linear regression was used to identify the association between clinical variables and different levels of anxiety. Results: A total of 115 patients including 59 males and 56 females with a mean age of 35 ± 11.34 years were included in the current study. Female patients were significantly more anxious about dental treatment compared to male patients. Linear regression showed that age and gender have a significant association with the pre-treatment anxiety level; however, types of treatment is not associated with the MDAS. Anxiety levels decreased for the majority of the patients after the treatment and types of treatment did not show any differences with the post-treatment anxiety level. Conclusions: Age and gender play an important role in dental anxiety; however, types of treatment are not associated with pre-treatment and post-treatment dental anxiety.

Interrater agreement between children's self-reported and their mothers' proxy-reported dental anxiety: a Chinese cross-sectional study

BACKGROUND

Children's dental anxiety is common in dental clinics. This study aimed to determine the interrater agreement between children's self-reported and their mothers' proxy-reported dental anxiety and its affecting factors.

METHODS

In this cross-sectional study performed in a dental clinic, primary school students and their mothers were assessed for enrollment eligibility. The Modified Dental Anxiety Scale plus Facial Image Scale (MDAS-FIS) was employed to test both the children's self-reported and their mothers' proxy-reported dental anxiety independently. The interrater agreement was analyzed using percentage agreement and the linear weighted kappa (k) coefficient. Factors affecting children's dental anxiety were analyzed using univariate and multivariate logistic regression models.

RESULTS

One hundred children and their mothers were enrolled. The median ages of the children and mothers were 8.5 and 40.0 years old, respectively, and 38.0% (38/100) of the children were female. The scores of children's self-reported dental anxiety were significantly higher than their mothers' proxy-reported dental anxiety (MDAS-Questions 1-5, all p < 0.05); moreover, there was no agreement between the two groups in terms of all anxiety hierarchies (kappa coefficient = 0.028, p = 0.593). In the univariate model, a total of seven factors (age, gender, maternal anxiety, number of dental visits, mother's presence or absence, oral health status, and having siblings or not) were involved for analysis, and age [every 1-year increase, odds ratio (OR) = 0.661, 95% confidence interval (CI) = 0.514-0.850, p = 0.001], several dental visits (every 1 visit increase, OR = 0.409, 95% CI = 0.190-0.880, p = 0.022), and mother presence (OR = 0.286, 95% CI = 0.114-0.714, p = 0.007) were affecting factors. In the multivariate model, only age (every 1 year increase) and maternal presence were associated with 0.697-fold (95% CI = 0.535-0.908, p = 0.007) and 0.362-fold (95% CI = 0.135-0.967, p = 0.043) decreases in the risk of children's dental anxiety during dental visits and treatment, respectively.

CONCLUSION

There was no significant agreement between elementary school students' self-reported dental anxiety and mothers' proxy ratings of children's dental anxiety, which suggests that self-reported dental anxiety by children should be encouraged and adopted, and the mother's presence during dental visits is strongly recommended.

The relationship between temperament and dental fear and anxiety: a systematic review

OBJECTIVE

To investigate the relationship between temperament traits and dental fear and anxiety (DFA) in children and adolescents by the means of a systematic review (PROSPERO #CRD42020207578).

METHODS

The PEO (Population, Exposure, and Outcome) strategy was followed using children and adolescents as the population, temperament as the exposure, and DFA as the outcome. A systematic search for observational studies (cross-sectional, case-control, and cohort) without restrictions on year or language of publication was performed in seven databases (PubMed, Web of Science, Scopus, Lilacs, Embase, Cochrane, and PsycINFO) in September 2021. Grey literature search was performed in OpenGrey, Google Scholar, and in the reference list of included studies. Study selection, data extraction, and risk of bias assessment were carried out independently by two reviewers. The Fowkes and Fulton Critical Assessment Guideline was used to assess methodological quality of each study included. The GRADE approach was performed to determine the certainty of evidence of relationship between temperament traits.

RESULTS

This study recovered 1362 articles, of which 12 were included. Despite the high heterogeneity of methodological aspects, qualitative synthesis by subgroups showed a positive association/correlation between emotionality, neuroticism, and shyness with DFA in children and adolescents. Different subgroups analysis showed similar results. Eight studies were classified as having low methodological quality.

CONCLUSION

The main shortcoming of the included studies is the high risk of bias and a very low certainty of evidence. Within its limitations, children and adolescents with a temperament-like emotionality/neuroticism and shyness are more likely to present higher DFA.

Effectiveness of a smartphone application on dental anxiety in adolescents: A randomized controlled trial

BACKGROUND

Dental anxiety is a common issue among adolescents. Despite the use of smartphones being an important part of their daily lives, only a few digital-based interventions for dental anxiety have been tested in randomized controlled trials (RCT).

AIM

The aim of this study was to evaluate a new smartphone application (App) named FALE, which was designed to demonstrate interest from the dentist to adolescent and to reduce dental anxiety.

DESIGN

This is a RCT in which 184 adolescents aged 10-19 years were randomly allocated into the intervention group (IG) or the control group (CG). The intervention was applied in the waiting room before the consultation at a dental clinic. The IG answered the FALE, which contained 14 questions-of which the first and last questions addressed anxiety, whereas the CG answered the question about anxiety twice with an interval between them.

RESULTS

There was a significant difference in the distribution of anxiety rating frequencies before and after the intervention period in both groups. For the IG, there was a reduction in anxiety after the intervention of 16.29%, and, in the CG, a reduction of 2.2% (p < .001).

CONCLUSION

The FALE App effectively reduced dental anxiety before the appointment.

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).

Management of fear and anxiety in dental treatments: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

This systematic review was to compare the effects of interventions for the management of fear and anxiety for dental treatments.

METHODS

This research project was applied to PubMed, CENTRAL, Web of Science, Cochrane library databases. The last search was run on March 31st, 2021. A list of references of relevant articles and previous reviews were checked. Qualitative and quantitative analyses were performed.

RESULTS

A total of 20 eligible randomized controlled trials were included, and 969 participations in experimental group and 892 participations in the control group were involved. Anxiety levels decreased more in intervention groups than in control groups (Z = 3.47, P = 0.0005, SMD = - 0.62, 95% CI - 0.98 to - 0.27). For adults, there was statistical difference between experimental and control groups [Z = 2.14, P = 0.03, 95% CI - 0.54 (- 1.03, - 0.04)], while there was not no such statistical difference in children and adolescents [Z = 1.62, P = 0.11, 95% CI - 0.60 (- 1.32, 0.13)]. Patients experienced a significant decrease in anxiety level using sedation drugs [Z = 2.44, P = 0.01, 95% CI - 0.61 (- 1.10, - 0.12)] and audio-visual distractions [Z = 3.1, P = 0.002, 95% CI - 0.86 (- 1.40, - 0.32)]. For the informative intervention groups, patients did not show significant difference than control groups [Z = 1.22, P = 0.22, 95% CI - 0.55 (- 1.43, 0. 33)]. There was no statistical difference in vital signs [Z = 1.39, P = 0.16, 95% CI - 0.25 (- 0.61, 0.10)] and pain levels [Z = 0.69, P = 0.49; SMD = - 0.06, 95% CI (0.27, 0.11)] between intervention and control groups.

CONCLUSIONS

Interventions should be used in managing anxiety and fear for dental treatment. It might be effective for anxiety alleviating for adults, but there was a low certainty of evidence that interventions could reduce anxiety level in children and adolescents. Sedation drugs and audio-visual distractions might be useful for managing dental fear and anxiety. Pain levels and vital signs could not be improved form our study. High-quality randomized clinical trials are required for further study.

Breathing out dental fear: A feasibility crossover study on the effectiveness of diaphragmatic breathing in children sitting on the dentist's chair

BACKGROUND

Anxiety related to the dental context is a clinically significant challenge. In children, dental fear is often accompanied by disruptive and uncooperative behaviours that can render treatment difficult. Although techniques to reduce children's anxiety exist, many have not been formally evaluated.

DESIGN

Diaphragmatic breathing has been shown to reduce fear and anxiety, but few investigations have evaluated whether it can reduce dental anxiety in children. This crossover study tested the effectiveness and feasibility of diaphragmatic breathing in twenty children undergoing dental care.

RESULTS

Compared with the treatment as usual, such a simple technique had significant benefits on mood, self-reported pain and autonomic balance, thus reducing sympathetic activation.

CONCLUSION

Diaphragmatic breathing is a low-cost, easy-to-implement technique suitable for daily dental practice, and is a promising tool for reducing negative effect and physiological distress in children with dental anxiety that results in more cooperative behaviours and reduced visit time.

The effect of socioeconomic aspects and dental history on pediatric patients' dental anxiety

This study aimed to characterize the profile of dental anxiety in pediatric patients, identifying the effect exerted by socioeconomic factors using dental data. A cross-sectional study design with a sample of 120 children aged 7-12 years old was used. Data relating to anxiety levels prior to dental care, socioeconomic aspects (family income, education level, child's school type), and child's dental history (previous dental appointments, previous treatment, caries experience) were collected. Additionally, participants completed the Brazilian version of the Children's Fear Survey Schedule- Dental Subscale (B-CFSS-DS) to assess dental anxiety. Descriptive analyses, chi-squared (X 2 ) tests, and Mann-Whitney U tests were performed, with a significance level of 5%. A total of 51 boys (42.5%) and 69 girls (57.5%) were included. There was no significant difference in dental anxiety between them. However, younger children had higher mean B-CFSS-DS scores (p = 0.036, Mann-Whitney). A higher prevalence of dental anxiety was found in participants from low-income families (p = 0.012, X 2 ) and in patients who did not receive endodontic treatment (p=0.034, X 2 ). Higher mean B-CFSS-DS scores were also observed in participants who did not receive endodontic treatment (p=0.001, Mann-Whitney) compared with those that did receive endodontic treatment. No relationship was found between education level, patient school type, first dental appointment, caries experience, and dental anxiety data. Younger children presented a profile of greater dental anxiety. Socioeconomic factors and dental data exerted some effect on dental anxiety, where children from low-income families and those not subjected to endodontic treatment displayed higher rates of dental anxiety.

Assessment of child's dental anxiety/fear and stress during dental treatment: a systematic review by CEDACORE

There is a lack of evidence on the correlation between salivary biomarkers and subjective measures of dental fear and anxiety in children. This systematic review aimed to retrieve the scientific evidence comparing the results of dental anxiety measured by salivary biomarkers with patient-reported outcomes in pediatric dental setting. The PECOS was as follows: population: pediatric patients aged ≤ 18 years; exposure: patient-reported outcome measures, such as scales and/or questionnaires; comparator: salivary biomarkers; outcome: anxiety, fear, phobia or stress during dental treatment; study design: observational studies or controlled trials. Electronic searches were conducted in PubMed, Scopus, Web of Science, and Ovid databases. Studies that compared scales/questionnaires and salivary biomarkers for the evaluation of dental anxiety, fear, and stress in children/adolescents during dental treatment were included. Certainty of evidence was assessed with GRADE. Risk of bias of the included studies was assessed with the Cochrane tool or the University of Adelaide tool. From the 314 studies identified, eight were included. Participants' age ranged from three to 13 years. The most used salivary biomarkers and instruments were cortisol and the Dental Subscale of the Children's Fear Survey Schedule, respectively. Most studies showed a weak correlation between objective and subjective measures. The main issues regarding bias were on allocation concealment, blinding of assessors, follow up, and exposure assessment. Certainty of evidence was low/very low. Evidence of salivary biomarkers and patient-reported outcome measures to investigate anxiety, fear and stress in children during in the dental environment is limited. There was no correlation between subjective and objective measures in almost all included studies.

The Effects of Providing Advance Notice and Stress-Coping Traits on Physiological Stress of Patients during Dental Treatment

Patients tend to feel stress in association with dental treatment due to uneasiness and fear. We investigated the effects of providing advance notice and stress-coping traits on the physiological stress of patients during dental treatment. Sixty non-dental professionals (male, n = 26; female, n = 34; mean age, 49.9 years) were recruited for this study and informed consent was obtained. Subjects were given simulated dental treatment including three stimuli, air, percussion and running of an air turbine, with or without advance notice of the stimulation during dental treatment. Real-time sympathetic nerve activity (SN) and parasympathetic nerve activity (PN) during the treatment were measured using a biological information monitor. The stress-coping traits of each subject were examined using the Lazarus-Type Stress Coping Inventory (SCI). Correlations between the nerve-activity and scores of eight stress-coping strategies of SCI and the presence/absence of advance notice were analyzed. Age, types of stimuli and order of stimuli significantly affected SN, while age, types of stimuli, and the pattern of stimulation significantly affected PN. The interaction of the stress-coping trait and presence/absence of advance notice significantly affected PN. Providing advance notice may have different effects on physiological stress depending on how the patient copes with stress.

The Relationship between Dental Fear and Anxiety, General Anxiety/Fear, Sensory Over-Responsivity, and Oral Health Behaviors and Outcomes: A Conceptual Model

Dental fear and anxiety (DFA) is common across the lifespan and represents a barrier to proper oral health behaviors and outcomes. The aim of this study is to present a conceptual model of the relationships between DFA, general anxiety/fear, sensory over-responsivity (SOR), and/or oral health behaviors and outcomes. Two rounds of literature searches were performed using the PubMed database. Included articles examined DFA, general anxiety/fear, SOR, catastrophizing, and/or oral health behaviors and outcomes in typically developing populations across the lifespan. The relationships between the constructs were recorded and organized into a conceptual model. A total of 188 articles were included. The results provided supporting evidence for relationships between DFA and all other constructs included in the model (general anxiety/fear, SOR, poor oral health, irregular dental attendance, dental behavior management problems [DBMP], and need for treatment with pharmacological methods). Additionally, SOR was associated with general anxiety/fear and DBMP; general anxiety/fear was linked to poor oral health, irregular attendance, and DBMP. This model provides a comprehensive view of the relationships between person factors (e.g., general anxiety/fear, SOR, and DFA) and oral health behaviors and outcomes. This is valuable in order to highlight connections between constructs that may be targeted in the development of new interventions to improve oral health behaviors and outcomes as well as the experience of DFA.

The Effect of Breathing Exercise Using Bubble Blower on Anxiety and Pain during Inferior Alveolar Nerve Block in Children Aged 7 to 10 Years: A Crossover Randomized Clinical Trial

Introduction. The aim of this study was to evaluate the effect of breathing exercise using bubble blower on anxiety and pain during inferior alveolar nerve block (IANB) in children aged 7 to 10 years. Materials and Methods. In this randomized crossover clinical trial, thirty-five children with moderate to severe anxiety requiring bilateral pulp therapy of mandibular primary molars were enrolled. Based on random lists, 18 children received the BE + IANB and 17 children received a routine IANB at the first session. This trend became reverse at the second visit for each child. Anxiety was measured using Facial Image Scale (FIS), blood pressure, and pulse rate. Face Leg Activity Cry Consolability (FLACC) scale and Wong–Baker Facial Pain Scale (WBFPS) were used for pain measurement. The Paired Samples Test, Wilcoxon Signed Rank Test, and Interclass Correlation Coefficient were used for data analysis. Results. The means of FLACC, WBFPS, FIS, blood pressure, and pulse rate were higher at the control visit. However, these differences were statistically significant only for FLACC scale and WBFPS ( $P$ value <0.05). In subgroup analysis, only girls and children without any previous dental treatment showed significant differences in FLACC scale and WBFPS between the control and bubble blower side ( $P$ value <0.05). Conclusion. Breathing exercise using a bubble blower may be an efficient distraction and relaxation method to decrease pain of 7- to 10-year-old children with moderate to severe anxiety during inferior alveolar nerve block. However, anxiety levels were lower when applying BE, and the differences were not statistically significant.

Evaluation of the relationship among dental fear, scaling and root planing and periodontal status using periodontitis stages: A retrospective study

Background/purpose

Patients with periodontal disease have higher dental fear levels, which may have negative effects on their clinical outcome during scaling and root planing (SRP). The present study used the new classification of periodontitis and validated questionnaires to assess the relationship among dental fear, SRP pain and periodontal status.

Materials and methods

A total of 120 periodontitis patients were enrolled and staging according to the new classification of periodontitis. SRP was performed, and the visual analog scale (VAS) to assess pain was used with every patient after treatment. Questionnaires, including Corah's Dental Anxiety Scale (DAS), Dental Fear Survey (DFS), and short-form Dental Anxiety Inventory (S-DAI) were implemented from the first attendance and subsequent visits after 6 months. The patients were grouped by DAS scores. The statistical analysis was performed using T-test, chi-square, Pearson and Spearman correlative analysis.

Results

Compared to pre-SRP treatment, the dental fear level on DFS was decreased in the posttreatment period for all periodontitis stages. There were no statistically significant differences in S-DAI and DAS between pretreatment and posttreatment periods in stage I and II; meanwhile, there were statistically differences in stage III and IV. The correlation among periodontitis stages, VAS and dental fear level was significant. The proportion of high periodontitis stages was increased in high dental fear group.

Conclusion

SRP can reduce dental fear levels in all periodontitis stages, especially in stage III and IV. Correlations exist among periodontal status, dental fear and SRP pain. High dental fear is associated with poor periodontal status.

Young patients' self-reported fear compared to professionals' assessments during invasive and non-invasive dental visits: a prospective, longitudinal study

Purpose

The main purpose was to study young patients’ self-reports on dental fear over a 5-year period, prospectively. Also, to compare these to professionals’ proxy reports for dental fear during invasive and non-invasive dental visits. The research question was, to what extent the self-reports and dental professionals’ proxy reports are congruent, and if there were patient age-dependent differences.

Methods

3134 patients from 11 public dental clinics, representing urban and rural areas, were invited. Four age cohorts were formed: 3, 7, 11, and 15 years of age and followed between the years 2008 and 2012. Dental examinations (non-invasive) and restorative treatments + extractions (invasive) were registered. During the treatments, self-reports regarding fear and professional proxy reports were registered: Not afraid at all = 0, little nervous = 1, quite afraid = 2, very scared = 3, terrified = 4.

Results

2363 patients completed the cohort periods (51% girls and 49% boys). In all, 9708 dental examinations, restorations and extractions were performed. The fear prevalence increased with the invasiveness of the dental procedure; 7–56%. For dental examinations and restorations, fear declined with ascending age. The highest fear prevalence was reported for dental extractions. Younger children reported fear more frequently than older children, p < 0.001. Frequent inconsistencies between self-reports and proxy reports were observed among the younger children (16%) compared to the older children (8%), p < 0.001.

Conclusion

Non-congruence was observed for self-reports and proxy reports regarding all age cohorts.

Psychometric Properties of Scared-C Scale in a Romanian Community Sample and Its Future Utility for Dental Practice

The psychological management of children and adolescents in need of pedodontics or orthodontic treatments continues to be an essential objective in dental activity because along with the accuracy of the techniques that are used, anxiety reduction, and knowledge of how to approach the patient are necessary for the treatment to be successful. Therefore, our study aimed to validate the Screen for Child Anxiety Related Emotional Disorders questionnaire, the child version of 41 items (SCARED-C) in the Romanian population for later use in pediatric dentistry. The instrument showed moderate to good internal consistency (α Cronbach from 0.63 to 0.91 for the total scale) and good test–retest reliability (0.70) on a subset of a sample comprising 85 children. A confirmatory factorial analysis (CFA) was conducted to test the factor structure of the Romanian version of the SCARED-C; the results showed that SCARED-C has good psychometric properties that can be used for screening anxiety in Romanian children and adolescents. The implications of using the SCARED-C in dental practice are discussed. Future studies need to be conducted to explore the convergent and discriminative validity of the instrument and its sensitivity to current DSM-V criteria. Application on a pediatric dental sample is also required.

Development of a Measure of Fearful Implicit Associations with Dental Stimuli in Youth

Youth with dental anxiety are at an increased risk of poor oral health but current tools used to identify dental anxiety in children in clinical settings are hampered by several limitations. This study assessed the psychometric properties of a measure of implicit associations with dental stimuli, the Affective Misattribution Procedure for dental stimuli (AMP-D) in 68 youth between the ages of 9 and 17 years. Measures of self-reported dental anxiety and parental perceptions of child dental anxiety were also administered. The internal consistency of the AMP-D was high (KR-20 = 0.96) and 1-week test-retest reliability was in the acceptable range (r = 0.75). The AMP-D was correlated with self-reported dental anxiety, providing evidence of construct validity. The psychometric properties of the AMP-D suggest it could be a useful tool in identifying youth with dental anxiety, particularly when concerns regarding self-representation may compromise the validity of self-reported anxiety.

Evaluating pain, fear, anxiety or stress/distress using children's drawings in paediatric dentistry: a scoping review

PURPOSE

The aim of this study was to systematically review the literature to answer the question: Can children's drawings represent a helping tool so the dentist can better understand the children's pain, fear, anxiety or stress/distress and their perception concerning the dentist and/or dental treatment?

METHODS

A scoping review was done. Cochrane Library, EMBASE, LILACS, LIVIVO, PsycINFO, PubMed, Scopus, Web of Science, and Grey literature was searched. Cross-sectional, quasi-experimental and qualitative studies in which patients were children and adolescents were included. Two authors independently selected studies to extract data and evaluate methodological quality by using Joanna Briggs Institute tools. Data collected included: characteristics of the studies, drawing evaluation/scales, main results and conclusion.

RESULTS

Out of 1037 papers were identified in search, 25 studies verified the emotional state and the children's perceptions regarding dental environment and the dentist and were included in the narrative synthesis. The spontaneous drawings were useful to identify the children's emotions. Drawings might be considered a helping tool to identify children and adolescents' perception in relation to dental treatment. Few studies used validated instruments. There were methodological disparities among studies.

CONCLUSIONS

The drawings can be considered a useful tool in identifying children's pain, fear, anxiety or stress/distress and perceptions about the dentist and/or dental treatment. Future studies with standardized analysis of the drawings are recommended. Code https://doi.org/10.17605/OSF.IO/U5BJH . "Retrospectively registered".

Turkish version of the faces version of the Modified Child Dental Anxiety Scale (MCDASf): translation, reliability, and validity

OBJECTIVES

To cross-culturally adapt of MCDAS_f into Turkish and to evaluate reliability and validity of the Turkish version of MCDAS_f using explorative factor analysis (EFA), confirmatory factor analysis (CFA), and receiver operating characteristic (ROC) analysis to form a less time consuming and easy to understand tool for measuring dental anxiety.

MATERIALS AND METHODS

A total of 300 children (174 females, 126 males) aged 6-12 years who were recruited at the Department of Paediatric Dentistry in RTEU at the first visit participated in the present study. For the internal consistency reliability, Cronbach's alpha was calculated. Intraclass correlation coefficients (ICCs) were calculated for test-retest reliability (n=67). Construct validity was determined by comparing with the Venham Picture Test (VPT). The factor structure was examined using EFA. CFA was used for dimensionality. The cut-off points of the Turkish version of MCDAS_f were plotted using a ROC curve.

RESULTS

The Turkish version of MCDAS_f showed high internal consistency (0.703) and an excellent ICC value (0.827). Good correlations were found between the global scores of MCDAS_f and VPT (r=0.632). Three factors were identified from EFA and verified with CFA. Discriminant validity was supported by high scores of females and younger children (p<0.05). The cut-off point was assigned as >24.50. The area under the ROC curve (AUC) was 0.921 (95% CI: 0.873-0.969).

CONCLUSIONS

The Turkish version of the MCDAS_f is a reliable and valid scale that satisfied psychometric properties.

CLINICAL RELEVANCE

The Turkish version of MCDAS_f is a usable tool for the measurement of dental anxiety among Turkish speaking children.

Adolescent Dental Fear and Anxiety: Background, Assessment, and Nonpharmacologic Behavior Guidance

Adolescence, the period from 11 to 21 years of age, bridges the chasm between childhood and adulthood. Adolescence can be challenging as bodies, cognition, and personality go through major transformations, but it is also a time of great joy as confident adults with a clear identity develop. Dentists need to be knowledgeable about the developmental characteristics of this group because some of the cognitive and emotional changes make adolescents vulnerable to new fears. Dentists must tailor behavior guidance to this developing psyche in a way that respects independence and promotes confidence to foster lifelong positive views of dentistry.

Is dental anxiety associated with the behavior of sedated children?

The aim of this cross-sectional study was to investigate factors associated with dental anxiety in children treated under moderate sedation. Prior to treatment, each child's dental anxiety was evaluated using the modified Venham Picture Test (VPT). Interviews were also conducted with parents/guardians to gather information on the child's dental anxiety (Corah's Dental Anxiety Scale [DAS]), age and sex, shyness or anxiety in the presence of strangers, and dental history, as well as socioeconomic factors. All the children were sedated, and had at least one tooth restored using the atraumatic restorative treatment technique. Child behavior was assessed using the Frankl scale. Data analysis involved descriptive statistics and bivariate tests. The median VPT score was 2.0 (range: 0 to 8). Children who were shy in the presence of strangers (yes: median 2.0 [0-8]; no: 0.5 [0-4]; p = 0.018), and those with negative behavior during dental care (negative: 3.0 [0-8]; positive: 1.0 [0-8]; p = 0.014) had greater anxiety. The child's dental anxiety was associated with the mother's education level (≤ 8 years: 4 [2-7]; > 8 years: 1 [0-8]; p = 0.016). The dental anxiety of children treated under sedation is associated with negative behavior, shyness, and the mother's education level.

A Short Form of the Children's Experiences of Dental Anxiety Measure (CEDAM): Validation and Evaluation of the CEDAM-8

Background: The Children’s Experiences of Dental Anxiety Measure (CEDAM-14) is a child-centred measure of dental anxiety which assesses a range of behaviours, thoughts and feelings/physical symptoms related to dental anxiety. A short form of the CEDAM-14, which places less time burden on patients and clinicians, could promote the feasibility and applicability of the CEDAM in clinical settings. The aim of the study was to develop a short version of the CEDAM that can be used to assess children’s dental anxiety in clinical practice. Methods: A short version of the CEDAM was developed using a combination of item impact and regression methods. Measurement properties including floor/ceiling effects, variance, criterion validity, construct validity and internal consistency was calculated for the short form. Results: An eight-item CEDAM short form was developed (CEDAM-8) that had good psychometric properties, was significantly correlated with the CEDAM measure (r = 0.90; p < 0.01), had minimal floor and ceiling effects (3.5% and 1.2%, respectively) and was sensitive to change. Conclusion: The CEDAM-8 is a useful assessment tool for clinicians that is easy and quick to administer and could help to understand children’s experiences of dental anxiety and changes in anxiety over time and following intervention.

Using process drama to explore the causes of dental anxiety in primary-school children

Background

Drama and role play can be unlisted as methods to allow children to view problems from a range of different perspectives that may differ from their own experience. Application of drama technique to assess the cause of dental fear and anxiety in a school setting is novel.

Aim

The aim of this study was to engage primary school children in the core investigation via participatory arts methodologies, namely, process drama to gain understanding of the causes of dental anxiety.

Design

Sixty-three children, aged 7–10 years from three primary schools participated in this study. A 90-min drama workshop was carried in each school. The children were encouraged to identify the causes of dental anxiety using key concepts from process drama. The sessions were audio-recorded and transcribed.

Results

Four key concepts emerged: (1) fear of the unknown; (2) unpleasant sensory experience; (3) society’s perception and portrayal of the dentist; and (4) learnt negative associations with the dentist. Within each four key concepts, two sub-themes were identified.

Conclusions

Role-playing and use of drama are a novel application and can reveal a considerable amount of information from the child’s perspective on the cause of dental fear and anxiety.

Inside the waiting room: process drama and dramatic distancing for involving children in research on dental anxiety

Background: Dental anxiety in children is a major health concern. Process drama adopts distancing techniques that allow children to examine the possible causes of dental anxiety safely and with authority. Using this method to inform paediatric dentistry is novel and could be adopted in other fields where children experience health-related anxiety.Methods: A 90-minute process drama workshop was conducted in three primary schools in Batley,West Yorkshire. Sixty-three children participated in the study. Sessions were audio-recorded, transcribed and thematic analysis conducted.Results: Four key concepts emerged: 1) Fear of the unknown; 2) Unpleasant sensory experience; 3) Society's perception and portrayal of the dentist and 4) Learnt negative associations with the dentist.Conclusion: Process drama offers a novel approach to develop an understanding of dental anxiety in children. It elicits critical insights from a child's perspective and offers a participatory model for engaging children in health research on sensitive issues.

Prevalence of dental anxiety in children and adolescents globally: A systematic review with meta-analyses

BACKGROUND

Dental anxiety (DA) negatively impacts oral health-related quality of life, and patients with DA usually require more dental treatment time.

AIM

To describe the global prevalence of DA in children and adolescents and to examine the influence of individual factors (age, sex, and caries experience) and variables related to DA measurement on pooled prevalence.

DESIGN

Systematic review with meta-analyses of observational studies published between 1985 and 2020 (PROSPERO CRD42014013879).

RESULTS

Searches yielded 1207 unique records; 224 full-text articles were screened, and 50 studies were used in the qualitative and quantitative synthesis. No study was considered as having high methodological quality according to 'The Joanna Briggs Institute assessment tool'. Overall pooled DA prevalence was 23.9% (95% CI 20.4, 27.3). Pooled prevalence in preschoolers, schoolchildren, and adolescents was as follows: 36.5% (95% CI 23.8, 49.2), 25.8% (95% CI 19.5, 32.1), and 13.3% (95% CI 9.5, 17.0), respectively. DA was significantly more prevalent in preschool children (one study) and schoolchildren (two studies) with caries experience and in female adolescents (one study). The scale used for DA assessment was shown to influence pooled prevalence in preschoolers and adolescents.

CONCLUSION

DA is a frequent problem in 3- to 18-year-olds worldwide, more prevalent in schoolchildren and preschool children than in adolescents.

Assessment of dental anxiety and dental phobia among adults in Lebanon

Background

Dental anxiety continues to be a widespread problem affecting adult populations. The primary aim of our study was to evaluate the psychometric properties of the Lebanese Arabic version of the Modified Dental Anxiety Scale (MDAS-A) and to identify the optimal cut-off for assessing dental anxiety and dental phobia among adults in Lebanon. In addition, we sought to assess dental anxiety and phobia as well as their correlates among Lebanese adult patients.

Methods

A cross-sectional study was carried out on a sample of 451 dental adult patients aged between 18 and 65 years old. Information about demographic characteristics, previous bad dental experience, trauma’s experience period, perception of a periodontal problem, sensation of nausea during dental treatment, the MDAS-A scale, and the Visual Analogue Scale for anxiety (VAS-A) were collected.

Results

MDAS-A exhibited evidence of adequate psychometric properties. The optimal cut-off was 12 for dental anxiety and 14 for dental phobia. Out of the total sample, 31.5% suffered from dental anxiety while 22.4% had a dental phobia. Multivariable analysis showed that the odds of dental anxiety and phobia were higher among females compared to males. Also, patients suffering from periodontal problem perceptions, bad dental experiences during childhood and adolescence, and the sensation of nausea during dental treatment were at a higher risk of developing dental anxiety and phobia compared to their counterparts. However, a higher level of education was found to be a protective factor against dental phobia among Lebanese adult patients.

Conclusion

The MDAS-A scale is a suitable tool for the routine assessment of dental anxiety and phobia among Lebanese adult patients. Identifying patients with dental anxiety at the earliest opportunity is of utmost importance for delivering successful dental care.

Children's dental anxiety (self and proxy reported) and its association with dental behaviour in a postgraduate dental hospital

PURPOSE

Child dental anxiety (CDA) and uncooperative dental behaviour are common. We aimed to assess the prevalence of CDA (self- and proxy- reported) in the United Arab Emirates (UAE) children related to their dental behaviour.

METHODS

Data were collected from 312 questionnaires obtained from 156 parent/child (mean age 9.95 ± 2.17 years) pairs attending a postgraduate dental hospital. Demographics, self/proxy- reported CDA scores via a six-question, five-point Likert scale, of the Modified CDA Scale-faces version (MCDAS-f: where ≥ 19 was severe CDA) and Frankl Behaviour Rating Scale (FBRS) scores were compared and analysed. Chi-square test, Pearson's correlation, Kappa- coefficient, one-way ANOVA and independent t test statistical analysis were used (p < 0.05).

RESULTS

The prevalence of self and proxy severe CDA was 22.4% (n = 35) and 33.3% (n = 52) respectively, with 9% (n = 14) being dentally- uncooperative. In both groups, extractions caused the highest CDA followed by injections and fillings (p < 0.001). The mean scores for self-reported/proxy-reported CDA were 15.02 (± 4.90)/15.70 (± 6.07) respectively. There was a positive linear correlation between self- and proxy- reported CDA scores and a negative linear correlation between self/proxy- reported CDA scores and the FBRS (p < 0.001). Self/proxy concordance of severe anxiety/none-to-moderate- anxiety was fair (68.6%, kappa = 0.23, p = 0.003). Both self/FBRS and proxy/FBRS concordance of severe anxiety/none-to-moderate- anxiety/behaviour was fair (78.8%, kappa = 0.23, p = 0.001) and (71.8%, kappa = 0.22, p < 0.001) respectively.

CONCLUSIONS

Considering the limitations of the present study in a UAE child population sample, the prevalence of CDA from extractions, injections and fillings was 22.4% (self- reported) and 33% (proxy reported). There was fair agreement between child- self and parent- proxy- reported CDA. Increased CDA led to uncooperative dental behaviour.

Patient-reported Outcomes (PROs) in clinical trials in paediatric dentistry

Patient-reported outcomes (PROs) are reports directly from patients without interpretation by clinicians or others and captured using validated patient-reported outcome measures (PROMs). These measures are increasingly employed in clinical practice and can be incorporated into clinical trials. Benefits of using PROs include reducing observer bias; eliciting unique views on aspects important to patients and increasing public accountability. Despite inclusion in clinical trials PRO data is often under-reported and the results may not be adopted into clinical practice due to concerns about the data generated. This review discusses what PROs are and how to measure them; the benefits of using PROs; how to choose an appropriate PROM to answer the research question; considerations for using PROs in paediatric dentistry and reporting guidelines. Finally, some examples of how PROs have been included in paediatric dentistry trials are given along with discussion of the development of core outcome sets and how these may improve reporting of PROs in the future.

Children's drawing as a measurement of dental anxiety in paediatric dentistry

BACKGROUND

Drawings can be used as a method of communication that represents an individual's self-concept, anxiety, attitude or conflict.

AIM

The purpose of this study was to evaluate children's drawing as a measure of dental anxiety in a dental setting.

DESIGN

Seventy-eight children, aged 6-12 years, were enrolled in this study. Pulp therapy and/or restorative treatment was performed during the first therapeutic session for all participants. Sound, Eye and Motor (SEM) and Frankl scales were used as an objective assessment of behaviour during treatment. After the treatment session, the children were instructed to draw a picture of a person at a dental clinic. Children's drawings were scored by a paediatric dentist and a psychologist using Child Drawing: Hospital (CD: H) scale and emotional indicators of Human Figure Drawings (HFD). The findings were compared with Frankl and SEM scores.

RESULTS

There was a significant negative correlation between Frankl and CD: H scores (P = .017), and a significant negative correlation was found between HFD and Frankl scores (P = .048).

CONCLUSION

Drawings can reveal a considerable amount of information about children's emotional status, and children's drawing can be a useful non-verbal self-report measure to evaluate anxiety in a paediatric dental setting.

A Novel Mobile App Intervention to Reduce Dental Anxiety in Infant Patients

Introduction: Anxiety and fear are feelings routinely associated with the dental experience, especially in childhood and adolescence. These have been prominent in the world for many years and are currently considered a public health issue. Since the young population is an assiduous user of virtual inputs, it was sought to develop a mobile application (app) with the function of reducing the levels of dental anxiety in children before dental treatment and evaluate its effectiveness. Materials and Methods: An app, entitled "Hello, Dentist!", containing dental anticipation videos, was developed by a multidisciplinary team and evaluated. This app was tested in two children groups (dental and school settings), aged 6-10 years. Children and caregivers answered sociodemographic questions. In addition, to measure children's dental anxiety, they completed the Children's Fear Survey Schedule before and after app utilization. Control groups were utilized. A total of 100 children were included in this study. Results: Anxiety levels were statistically lower in the groups using the app when compared with their control groups (p < 0.05). The effectiveness in reducing anxiety was greater when the initial anxiety values were higher, as seen in the dental environment group (p = 0.029). Dental procedures previously experienced, as well as the environment (dental or school) in which children were inserted, were factors that influenced their initial anxiety levels. Conclusions: The creation and utilization of an app to reduce dental anxiety are feasible and effective. The app developed decreased children's anxiety, especially in the dental setting, by anticipating dental situation.

The effects of lavender aromatherapy on stress and pain perception in children during dental treatment: A randomized clinical trial

BACKGROUND AND PURPOSE

Reducing dental anxiety is a major aspect of childmanagement in dental visits. This crossover randomized clinical trial was designed to determine the effect of lavender aromatherapy on anxiety level during dental treatment and pain perception during dental injection in children.

MATERIALS AND METHODS

Twenty-four children aged 7-9 years received restorative treatment with lavender aromatherapy in the intervention session and without aroma in the control session. Salivary cortisol and pulse rate were measured to evaluate child's anxiety level and the Face Rating Scale (FRS) was used for assessing the pain perception during injection in both visits.

RESULTS

The treatment effect on salivary cortisol, pulse rate, and FRS score was -8.01 ± 0.92 nmol/l, -11.17 ± 1.28 (in minutes), and -2.00 ± 0.41 respectively, which was statistically significant (P < 0.001).

CONCLUSION

Lavender aromatherapy can decrease dental anxiety and experienced pain in dental setting.

An Introduction to Assessing Dental Fear and Anxiety in Children

Fear and anxiety constitute an important theme in dentistry, especially with children. Anxiety and the fear of pain during dental treatment can lead to avoidance behaviour, which contributes to perpetuating fear and anxiety of dental care. Understanding and assessing dental fear and anxiety in children is important for delivering successful dental care with high satisfaction in this age group. Among the vast assessment method options available today, self-report assessment, parental proxy assessment, observation-based assessment, and physiological assessment are the four major types for dental fear and anxiety in children. Each method has its own merits and limitations. The selection of a method should be based on the objectives, validity, and setting of the assessment. The aim of this paper is to review and discuss the assessment methods for dental fear and anxiety in children.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

BACKGROUND

Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated.

OBJECTIVES

The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression.

DESIGN

This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit.

SETTING

This trial was set in primary dental care in Scotland, England and Wales.

PARTICIPANTS

Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis.

INTERVENTIONS

Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth).

MAIN OUTCOME MEASURES

The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period.

RESULTS

A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis.

CONCLUSIONS

There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

FUTURE WORK

Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044005.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

Children's Perceptions of Dentist's Attire and Environment: A Systematic Review and Meta-analysis

Aim

To assess the children's perceptions of the dentist's attire and environment. The protocol is available in the PROSPERO database.

Search strategies

Systematic searches in the databases were performed in Cochrane, Latin American and Caribbean Health Sciences, PubMed, PsycINFO, Scopus, and Web of Science from their inception to December 12, 2019, Google Scholar, Open Grey, and ProQuest Dissertations.

Selection criteria

Criteria consisted of descriptive studies regarding the above matter while two authors assessed the information. The risk of bias was also performed.

Results

Databases showed 1,544 papers and a two-phase assessment selected 21 studies in narrative and 9 in the quantitative synthesis. A meta-analysis demonstrated no difference between white coat and child-friendly attire (OR = 0.63; 95% CI 0.16-2.49; n = 3,706) and a decorated vs plain dental clinic was the preference of the children's majority (OR = 8.75; 95% CI 1.21-63.37; n = 150).

Conclusion

It can be concluded that there is no difference in the children's perception, white coat vs child-friendly attire; however, children prefer a decorated dental clinic.

How to cite this article

Oliveira LB, Massignan C, De Carvalho RM, et al. Children's Perceptions of Dentist's Attire and Environment: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent 2020;13(6):700-716.

The oral health of dentally phobic 12- and 15-year-olds: a descriptive analysis of the 2013 Child Dental Health Survey

Introduction Dental anxiety has been shown to be related to poorer oral health. Limited data exist exploring the relationship between oral health status and dental anxiety in non-clinical populations in children.Aim To compare the oral health of phobic and non-phobic children aged 12 and 15 years.Design Secondary analysis of data from 12-year-old and 15-year-old children in the Child Dental Health Survey 2013.Materials and methods Participants were grouped into non-phobic and phobic groups, depending on their self-reported dental anxiety (MDAS). Descriptive analyses compared the two groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact.Results A total of 601 children were classed as dentally phobic with 4,144 classed as non-phobic. Dental phobic children were more likely to be female, had more active decay and untreated dental disease, and rated their dental health as poorer. Phobic children were more likely to report that their oral health had a negative effect on their everyday life. This group were less likely to brush their teeth regularly or attend the dentist for check-ups.Conclusions Dentally phobic children have more dental disease and express greater impact on their everyday life.

Child dental fear and past dental experience: comparison of parents' and children's ratings

PURPOSE

To compare the parental and child versions of the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) and the parental and child evaluations of the Child's Past Dental Experience (CPDE) in 4- to 12-year-old children in a sample from Greece.

METHODS

537 families (652 children) with 4- to 12-year-old children seeking dental care either at a University paediatric dental clinic (UC) (50.8%) or a paediatric private practice (PP) participated. Parents completed a sociodemographic questionnaire and the parental Greek version of the CFSS-DS, and children independently completed the child's Greek version. All family members answered questions about CPDE. Statistical analyses were based on multilevel models (p < 0.05).

RESULTS

Mothers' and fathers' mean CFSS-DS total scores were not significantly different from each other (p = 0.655), but were significantly higher than the scores of their sons and daughters (p < 0.001), regardless of the child's age. There was a negative association between mother's age and CFSS-DS agreement, but not for fathers. There was poor agreement for CPDE ratings between children and both parents, regardless of gender. Parents' ratings of CPDE were not related to their assessment of their children's dental fear, whilst the children's ratings of their CPDE were significantly related to their current dental fear. Location (UC or PP) had no significant influence on CFSS-DS or CPDE parental-child differences.

CONCLUSIONS

Both parents overestimated their sons' and daughters' dental fear. There was poor agreement on CPDE evaluation between parents and children. Parental CFSS-DS and CPDE evaluations are poor indicators of children's dental fear and prior dental experience.

'Message to Dentist': Facilitating Communication with Dentally Anxious Children

Dental anxiety affects children worldwide and can have negative consequences on oral health. This study aimed to evaluate a novel communication aid ‘message to dentist’ (MTD), as part of a wider cognitive behavioural therapy approach to reduce dental anxiety in young patients. Dentally anxious children, aged 9–16 years, were invited to complete the MTD proforma, before and following their course of treatment. They scored how worried they were and their anticipated pain levels on a scale of 1–10 (10 being the worst outcome). They also wrote down their coping plans and post-treatment reflections. One hundred and five children, from a UK general dental practice and a hospital clinic, were included. They had a mean age of 11.6 years, and 65% were female. There was a significant reduction in self-report worry (from 4.9 to 2.1) and anticipated pain (from 5.1 to 2.0) scores (p < 0.05, paired t-test). Many children (30%) used listening to music/audiobook as a coping strategy. Thematic analysis revealed concerns around pain, uncertainty, errors and specific procedures. The MTD proforma proved an effective means of facilitating communication between anxious children and the dental team, allowing them to identify their worries and make personalised coping plans.

Association of temperament with dental anxiety and behaviour of the preschool child during the initial dental visit

The aim of this study was to investigate whether there is an association between temperament characteristics of preschool children, dental anxiety, and their dental behaviour. A total of 100 children, aged 3-5 yr, who were attending their initial dental visit accompanied by a parent, were included in this cross-sectional study. Dental anxiety of children was measured using the Facial Image Scale. The behaviour of children during the initial oral examination and oral prophylaxis was assessed using Frankl's behaviour rating scale. Temperament was assessed using Emotionality, Activity, Shyness Temperament Survey for Children (parental ratings). Statistically significant weak linear positive correlations were seen between the following: the percentage duration of definitely negative behaviour and shyness scores (r_s  = 0.28); anxiety level and emotionality scores (r_s  = 0.28); and anxiety level and shyness scores (r_s  = 0.26). Multinomial logistic regression analysis revealed that children with higher anxiety had higher odds of showing definitely negative behaviour, which decreased with increasing age of the child. Emotionality and shyness temperaments may be weakly associated with dental anxiety, and shyness may be weakly associated with the dental behaviour of the preschool child. Definitely negative dental behaviour is associated with dental anxiety and age of the child.

Patient-reported outcomes associated with different restorative techniques in pediatric dentistry: A systematic review and MTC meta-analysis

BACKGROUND

Despite the increasing number of studies evaluating patient reported outcome measures (PROs), there is no clearness regarding which restorative treatment offers major benefits based on the pediatric patient perspective.

AIM

To compare different restorative techniques in pediatric dentistry regarding patient-reported outcomes.

DESIGN

Literature searching was carried out on prospective studies indexed in PubMed, Scopus and OpenGrey. A Mixed Treatment Comparisons (MTC) meta-analysis was undertaken considering the results from reviewed studies. Anxiety, pain and quality of life were extracted as mean with standard deviation, percentage of pain, and mean difference of scores with standard deviation, respectively. For direct comparisons, data were combined using a random-effect model. Heterogeneity was assessed with the I2 statistic. For indirect comparisons, fixed and random effects were chosen through comparison of competing models based on the Deviance Information Criteria (DIC). The expected efficacy ranking based on the posterior probabilities of all treatment rankings was also calculated.

RESULTS

An initial search resulted in 4,322 articles, of which 17 were finally selected. Due to unavailability of data, only pain, anxiety and oral health related quality of life (OHRQoL) were statistically analyzed. The difference in means (95% CI) of anxiety between treatments using only hand instruments with or without chemomechanical agents were -5.35 (-6.42 to -4.20) and -5.79 (-7.77 to -3.79) respectively when compared to conventional treatment using rotary instruments and/or local anesthesia. Regarding pain, there was a trend for treatments without rotary instruments and local anesthesia to be less frequently reported as painful. No statistical difference was found intragroup nor among treatments for OHRQoL.

CONCLUSIONS

Anxiety and pain are directly related with more invasive restorative treatments. On the other hand, quality of life is not improved regardless of the restorative technique used. Further well-designed prospective studies regarding PROs in children are still necessary.

The long-term effect of previous dental treatment under general anaesthesia on children's dental fear and anxiety

BACKGROUND

Dental treatment under general anaesthesia (DGA) is deemed to contribute to children's dental fear and anxiety (DFA), both in the short term and long term.

OBJECTIVE

To compare DFA between children who had previous DGA and those who did not.

METHODS

A cross-sectional survey included 5- to 12-year-old children who had undergone DGA (n = 43) and a control group who had not (n = 55). Questionnaires were completed by parents regarding sociodemographic and dental profiles. Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) and the Modified Child Dental Anxiety Scale (faces) (MCDASf) were completed by children.

RESULTS

The mean age of the control group and the DGA group was 9.5 ± 1.7 and 8.8 ± 1.5 years old, respectively (P > 0.05). The time passed since DGA was experienced ranged between 1.2 and 6.9 years ago (mean: 4.2 ± 1.1 years). The mean CFSS-DS and MCDASf scores for the DGA group (34.3 and 20.4, respectively) were significantly greater when compared to the control group (23.6 and 12.7, respectively) (P < 0.001).

CONCLUSION

Children who experienced DGA are a high-risk group for DFA several years after the procedure. The DGA status could be used for identifying anxious children to promote better behaviour management.

Angel or Devil? Dentists and Dental Students Conceptions of Pediatric Dental Patients through Metaphor Analysis

PURPOSE

The aim of this qualitative study was to identify the conceptions of dentists and dental students (DSs) about pediatric dental patients (PDPs) using metaphor analysis.

STUDY DESIGN

The study group (N = 259) consisted of dentists and DSs. Participants completed the sentence "A pediatric dental patient is like ... because …..." in order to reveal the metaphors they use about the concept of PDPs. The data were analyzed using the mixed-methods: qualitative (metaphor analysis) and quantitative (chi-square) data analysis techniques.

RESULTS

The dentists and DSs produced 259 metaphors. These metaphors were gathered under six different conceptual categories that define a PDP as unpredictable, dangerous, uncontrollable, requiring care and sensitivity, valuable, and orientable. The most important factors leading to these conceptions were the uncooperativeness of some PDPs and the effectiveness of behavior management.

CONCLUSIONS

The results of this study indicate that there was no significant difference among DSs, general dentists and specialist dentists with respect to six conceptual categories that identify the conceptions about PDPs.