Age of onset of dental anxiety

Salivary Markers as Potential Stress Descriptors for Pediatric Dental Patients: A Literature Review

Dental fear and anxiety are frequently identified as major contributing factors to non-compliance, uncooperativeness, and difficulties during dental procedures in pediatric patients. These issues can lead to avoidance of dental treatment, resulting in long-term negative consequences for oral health and overall well-being. The assessment and quantification of psychological functioning (i.e., dental fear, anxiety, and self-perceived stress) has traditionally relied on self-reported questionnaires validated for the pediatric population. While this approach is cost-effective and non-invasive, it relies on subjective self-reported data, oftentimes influenced by parental or guardian interaction, especially in young children. Salivary diagnostics has recently emerged as an objective method for the procurement of biological molecules that serve as biomarkers for a variety of oral and systemic conditions. This literature review aims to comprehensively summarize the available literature on the correlation between psychological and salivary physiological measurements assessing dental fear, dental anxiety, and self-perceived stress in pediatric dental patients, highlighting the advantages and disadvantages of each method of assessment. Four databases (PubMed®, PsycInfo, Dentistry & Oral Sciences Source, and Web of Science) were searched for published articles, in the English language, assessing the correlation between psychological and physiological distress in children undergoing dental procedures. Studies on pediatric patients reveal positive correlations between salivary cortisol and dental fear, stress, and anxiety, especially in returning patients. Conversely, findings on salivary alpha-amylase and secretory immunoglobulin A were inconsistent, with some studies suggesting correlations with dental fear and prior dental experiences.

A software-based observational coding approach for evaluating paediatric dental pain, anxiety, and fear

BACKGROUND

Dental practitioners desire non-pharmacological methods to alleviate anxiety, fear, and pain in children receiving dental care; high-quality evidence, however, is required to evaluate methods' efficacy.

AIM

This study aimed to develop and validate an observation-based coding approach (paediatric dental pain, anxiety, and fear coding approach [PAFCA]) to evaluate non-pharmacological behavior management techniques for anxiety, fear, and pain.

DESIGN

Objective (video-based) and subjective (self-reported) anxiety, fear, and pain data were collected from a pilot clinical trial evaluating animal-assisted therapy (AAT) in paediatric dentistry, in which 37 children aged 7-14 were assigned to AAT or control before dental treatment (restorations or extractions). A coding approach utilizing a codebook, a gold standard calibration video, and a user training guide was developed. Trained examiners coded the gold standard video for inter-rater agreement, and masked, calibrated examiners analyzed videos using the Noldus Observer XT software.

RESULTS

A novel, software-based coding approach was developed, with moderately high inter-rater agreement. Using PAFCA, we found children reporting higher levels of pain, fear, and anxiety exhibited treatment-interfering behaviors, including crying/moaning, attempts to dislodge instruments, and more upper and lower body movements.

CONCLUSION

PAFCA shows promise as a reliable tool for assessing anxiety, pain, and fear in behavioral research for paediatric dentistry.

Who requires dental treatment under general anesthesia due to pain and severe dental anxiety? Findings from panoramic X-ray images and anamnesis

OBJECTIVE

The aims were to describe the dental status and mental and somatic health profile of patients with severe dental anxiety requiring dental treatment under general anesthesia (GA) in Rogaland County, Norway (2018-2021), and to compare patients with and without reported abuse history.

MATERIAL AND METHODS

Dental status was assessed by panoramic X-rays. General health variables were collected from patient records. Statistical comparisons of patients with and without abuse experience by tests of association (significance level p < 0.05).  Results: 38 women and 18 men (mean ± standard deviation [SD]: 37.9 ± 9.2 years) were included; 27 reported abuse experience. Dental assessment showed 4.6 ± 3.8 missing teeth, 4.8 ± 3.0 root remnants, 5.8 ± 3.7 teeth with caries and 2.6 ± 1.9 teeth with apical periodontitis, among patients with ≥1 of the respective findings. 57.1% used analgesics due to dental pain. 55.4% had comorbid psychiatric conditions; 35.7% used psychopharmaceuticals. There were no statistical differences in dental variables but the abuse experience group had higher frequencies of comorbid psychiatric disorders (p = 0.01) and mixed somatic conditions (p = 0.03).

CONCLUSIONS

Patients with severe dental anxiety requiring dental treatment under GA have complex health problems. They need access to treatment under GA, as treatment of serious odontogenic conditions is otherwise unmanageable.

Is the Modified Dental Anxiety Scale (MDAS) a Single or Two Construct Measure? A Theoretical and Pragmatic Perspective

Background: The MDAS questionnaire is one of a number of scales available to assess dental anxiety. It is widely used and translated into many world languages; however, it lacks an explicit theoretical backdrop to the content and structure of the measure. This paper draws upon original expositions of dental anxiety: how it develops, is maintained, and how this draws attention to a re-evaluation of the measure. To assist this inspection it was proposed to investigate a two latent construct formulation through a stepwise analysis using data from a representative survey of English respondents on their oral health (the Adult Dental Health Survey). Aim: To present a brief theoretical framework to underpin the measure and, as part of this study's objectives, to provide some evidence to support the measure's potential two-construct structure. Method: Narrative review, structural equation modelling, and testing of specific associations to indicate a two latent construct formulation. Data included the MDAS items (where items 1 and 2 comprise the anticipatory subscale, and items 3 to 5 describe the treatment-related subscale). These items were completed by the representative sample of respondents from the most recent Adult Dental Health Survey conducted in 2009. Results: The two latent construct solution for describing dental anxiety was supported. The anticipated and treatment-related subscales could be discriminated, although they were strongly correlated, demonstrating overlap. Comparison of how each construct varied across the three age groups suggests an interesting heterogeneity. In addition, the two constructs behaved differently when acknowledging previous experience of respondents' last dental visit. Anticipatory dental anxiety was more strongly related to oral health-related quality of life (OHRQoL) than treatment-related dental anxiety as predicted. This partial evidence from empirical data and previous reports in other studies suggests that the separation of the MDAS measure into the two subscales may be warranted. Discussion: Researchers are recommended to report not only the total score of the MDAS in their studies but also consider presenting the two subscale scores, namely, anticipatory and treatment-related dental anxiety. Further work is indicated to determine if clinicians may find the subscales of use when assessing their patients.

Questionnaire survey on the clinical application of Hall technique preformed metal crowns in caries of primary molars in China

Objective

To analyze the clinical application and limiting factors of the Hall technique (HT) preformed metal crowns in caries of primary molars and to provide reference for its clinical application based on a questionnaire survey.

Materials and methods

From June to December 2022, a questionnaire was distributed to pediatric dentists through the WeChat platform using "Questionnaire Star" to analyze the clinical application and influencing factors of the HT preformed metal crowns in caries of primary molars.

Results

A total of 700 survey questionnaires were distributed, and 650 valid questionnaires were recovered, with a effectiveness rate of 92.86%. In terms of the awareness level of the HT, only 11.08% of pediatric dentists fully understood, while 19.85% of those were completely unaware; In terms of the understanding methods, classes study accounted for 47.60%, and 28.79% of pediatric dentists understood through literature; In terms of the application of the HT, 46.15% of pediatric dentists had applied it, only 11.23% had frequently applied it, and 53.85% had never applied it; In terms of the usage time, the highest proportion was between 1 and 3 years, accounting for 40.33%, and only 9.67% were over 5 years; In terms of the choosing of indications, only 26.62% of pediatric dentists could select indications correctly; Regarding the choice of treatment methods for children who do not cooperate, only 19.54% of pediatric dentists chose the HT. The education background and nature of the workplace had a statistically significant difference in the application of the HT, the number of years of application, the selection of indications, and the choice of treatment methods for children who do not cooperate.

Conclusions

The survey showed that the awareness level and application frequency of the HT were relatively low in China. The understanding methods mainly learned through classes study.

Clinical relevance

It is necessary to further promote the development of continuing education projects with the theme of clinical application of the HT and the guidance of clinical operation standards, in order to promote the clinical popularization of it in China.

Auxillary aids for pain and anxiety reduction during dental local anesthesia in pediatric patients: a systematic review

AIMS/OBJECTIVES

This systematic review aimed to evaluate the effectiveness of auxiliary aids-Transcutaneous Electrical Nerve Stimulation (TENS), vibrotactile devices, and Low-Level Laser Therapy (LLLT) in reducing pain and anxiety during dental local anesthesia in pediatric patients.

METHODS

The review followed PRISMA guidelines, employing a comprehensive search strategy across multiple databases (PubMed, Cochrane, EBSCO, LILACS, Google Scholar, and Embase) from 2014 to July 2024. Eligibility criteria were based on the PICOS framework, focusing on randomized clinical trials and clinical studies involving pediatric patients undergoing dental procedures with local anesthesia. The interventions included TENS, vibrotactile devices, or LLLT. Pain and anxiety were assessed using validated scales such as the Wong-Baker Faces Pain Rating Scale and physiological measures like heart rate.

RESULTS

Nineteen studies with a total of 1094 pediatric patients aged 4-12 were included. TENS and vibrotactile devices consistently showed significant reductions in pain and anxiety compared to standard methods. LLLT results were more variable, with some studies reporting significant pain reduction while others showed no significant difference. Meta-analysis was not possible due to heterogeneity among the studies. Overall, TENS and vibrotactile devices were more effective in alleviating injection-related pain, especially when combined with cold applications or topical anesthetics.

DISCUSSION

The findings highlight the potential of these auxillary aids as non-invasive and effective adjuncts for reducing pain and anxiety in pediatric dental procedures. LLLT showed mixed outcomes, likely due to variability in application protocols, suggesting a need for standardized methods. While all interventions demonstrated promise, inconsistencies in study designs and subjective measures limit the generalizability of the results.

CONCLUSIONS

TENS and vibrotactile devices are effective auxiliary aids for reducing pain and anxiety during dental local anesthesia in children. Further research is required to optimize LLLT protocols and standardize intervention applications to achieve consistent results across studies.

Temperament and past behaviour can predict behaviour success for nitrous oxide sedation

BACKGROUND

There is currently insufficient evidence on potential predictors of a child's behaviour with nitrous oxide (N2O) sedation.

AIM

To examine the association between a child's temperament and behavioural outcomes during dental treatment with N2O sedation, and the child's perception to N2O sedation.

DESIGN

At the first visit (dental treatment visit), temperament was assessed using the Child Behaviour Questionnaire-Short Form and behaviour was assessed by an independent rater using the Venham Behaviour Rating Scale. At the second visit, the child's experience with N2O sedation was elicited.

RESULTS

Seventy-two healthy children aged between 36 and 95 months were recruited. Planned dental treatment was completed in 84.7% of the subjects. Venham behaviour success <3 and Venham behaviour success <1 were achieved in 73.6% and 33.3%, respectively. The temperament domain of effortful control was associated with Venham behaviour score (ρ = -0.266, p = .024) and Venham behaviour success <1 (OR = 3.506, 95% CI = 1.328-9.259, p = .011). Baseline Frankl behaviour score was significantly associated with all behavioural outcomes. Venham behaviour success <3 was significantly associated with a child reporting to have enjoyed the dental treatment visit (p = .026).

CONCLUSION

Effortful control and baseline behaviour were associated with behavioural outcomes of N2O sedation and can be used to predict a child's behaviour.

Comparison of Parental and Children's Dental Anxiety Levels Using the Modified Dental Anxiety Scale and Modified Short State-Trait Anxiety Inventory (EMOJI) Scale

BACKGROUND

The study aimed to assess dental anxiety (self and proxy reported) using a Modified Dental Anxiety Scale (MDAS) and modified short State-Trait Anxiety Inventory scale (Emoji).

METHODS

200 children visiting the pediatric dental clinic at the College of Dentistry at Prince Sattam bin Abdulaziz University were recruited to assess their anxiety levels. The anxiety score was measured before and after the treatment using a short STAI scale and MDAS of 200 children using a Modified Dental Anxiety Scale (MDAS) and a modified short STAI (Emoji) Scale.

RESULTS

The perception of children with MDAS was found to have the highest mean score of 14.54 ± 3.82 before the dental procedure compared to the mean score of 9.40 ± 2.90 after the dental procedure. This difference was statistically significant (p < 0.001). A statistically significant difference was observed in MDAS after the dental procedure and, in short, STAI before the dental procedure.

CONCLUSION

All children improved their dental anxiety levels before and after the procedure. Therefore, procedural experience may improve the child's response.

Changes of Dental Implant Surgery-Related Anxiety and Pain with Respect to ASA-Physical Status

Background/Objectives: Rehabilitation of missing teeth with dental implants is a strong trigger of dental anxiety. The sympathetic response caused by anxiety can lead to cardiovascular and cerebrovascular incidents, especially in patients at systemic risk (ASA Physical Status-II and ASA Physical Status-III). Dental anxiety can affect physical health by activating the sympathetic response, and the patient's physical health status may also affect dental anxiety. The aim of this study was to analyze the factors that may reduce anxiety and pain, considering the patient's physical health status according to American Society of Anesthesiologists (ASA-PS). Methods: A total of 562 implants were placed under local anesthesia in 201 patients with ASA PS-I (healthy) and ASA PS-II and III (comorbid). The effect of patient-, dentist-, and surgery-related variables on dental anxiety and pain perception were evaluated. Modified Corah Dental Anxiety Scale and Numerical Rating Scale for Pain scores were measured and recorded preoperatively (T0) and 1 week postoperatively (T1). The effects of the associated variables were analyzed using binary logistic regression and non-parametric tests (p < 0.05). Results: Age (OR = 1.089), gender (OR = 6.493), ASA-PS (OR = 13.912), and the number of placed implants (OR = 0.807) were significantly associated with reduction in dental anxiety. There were statistically significant differences between the study groups in terms of mDAS score reduction (p = 0.028). Conclusions: ASA-PS, gender and the number of placed implants affected the anxiety of the patients. Age and number of implants seem to be variables with a relative influence that depends on other factors.

Oral health with focus on dental fear and dental caries in Swedish preschool child populations attending public dental health care: Trends over 30 years

OBJECTIVES

To study changes in oral health with focus on reported dental fear prevalence and interrelationships between dental fear and prevalence of dental caries and performed restorative dental treatment in preschool child populations attending regular public dental health care between 1983 and 2013.

METHODS

Every 10 years, random samples of about 100 children aged 3 and 5 years, respectively, took part in cross-sectional studies based on oral examination and a questionnaire. One question, put to the child and answered by the parent, mirrored dental fear: "What do you feel at the prospect of an appointment with a dentist?". Agreement to at least one of three alternatives, ill at ease, frightened and sick, indicated dental fear. Frightened and/or sick mirrored severe dental fear. 79%-94% of the samples answered the question and constituted the study group. Prevalence of caries and number of filled tooth surfaces were recorded. Dental parameters were presented in mean values.

RESULTS

During the 30 years, dental fear prevalence was fairly constant. 21% of 3-year-olds and 15% of 5-year-olds reported dental fear in 2013. Positive relationships between dental fear prevalence and caries prevalence and number of filled tooth surfaces were found. Dental caries was reduced during the study time, but to a lesser degree in children with dental fear compared to children without dental fear.

CONCLUSIONS

Although children were offered public dental health care, the prevalence of dental fear remained high. Children with dental fear are caries risk individuals.

Dental anxiety and dental care - a comparison between Albania and Germany

BACKGROUND

The present study is the first in Albania on dental fear and dental anxiety and also in the field of psychosocial medicine. The purpose of this study was to find out whether there are differences in dental anxiety using the Dental Anxiety Scale, their level of psychological distress using the Brief Symptom Inventory-18 and the evaluation of oral health among Albanian and German patients.

METHODS

This study was conducted in the period from December 2019 to July 2020, a sample of N = 263 patients (133 Germans, 130 Albanians) using the Dental Anxiety Scale questionnaires to determine anxiety before dental treatment and the Brief Symptom Inventory-18 to evaluate psychological distress. Moreover, the patients answered questions regarding their oral health and dental care. In Germany, there were four refusals to entrance in the study due to various reasons, in contrast to Albania, where there were no refusals at all For the purposes of this study, data on both populations aged 14 years and older were used.

RESULTS

The questionnaires results were calculated for all participants. The current subjective health status of Albanian patients was assessed to be significantly worse than that of German patients (p < 0,000). Germans were more susceptible to signs of Anxiety (p < 0,000), Depression and Somatization and scored higher on the Dental Anxiety Scale and the Global Severity Index (p < 0,000) than Albanian patients. Additionally Albanian patients scored significantly lower on the preventive care index (p < 0,000). Despite an elevated DAS anxiety level, German patients reported going to the dentist more frequently than Albanian patients.

CONCLUSION

The results showed that between both populations differences in dental anxiety, psychological distress and oral health exists. Patients from Germany report more psychological distress and described more dental anxiety compared to Albanian patients. Albanian patients reported not utilization on oral health care.The implementation of educational programs and preventive measures, would contribute to raising awareness about the importance of oral health and increased use of dental services.

Interdisciplinary CBT treatment for patients with odontophobia and dental anxiety related to psychological trauma experiences: a case series

BACKGROUND

While cognitive-behavioural therapy (CBT) is a well-established treatment for odontophobia, research is sparse regarding its effect on patients with dental anxiety related to psychological trauma experiences. This study aimed to evaluate changes in symptoms and acceptability of interdisciplinary Torture, Abuse, and Dental Anxiety (TADA) team treatment for patients with odontophobia or dental anxiety. We also wanted to describe the sample's oral health status. The TADA teams offer targeted anxiety treatment and adapted dental treatment using a CBT approach.

METHODS

The study used a naturalistic, case series design and included 20 consecutively referred outpatients at a public TADA dental clinic. Pre- and post-treatment assessments included questionnaires related to the degree of dental anxiety, post-traumatic stress, generalized anxiety, and depression. Patients underwent a panoramic X-ray before treatment. Before dental restoration, patients underwent an oral health examination to determine the mucosal and plaque score (MPS) and the total number of decayed, missing, and filled teeth (DMFT). Patients were referred to dentist teams for further dental treatment and rehabilitation (phase 2) after completing CBT in the TADA team (Phase 1). Results from the dental treatment in phase 2 is not included in this study.

RESULTS

All patients completed the CBT treatment. There were significant improvements in symptoms of dental anxiety, post-traumatic stress, and depression and moderate changes in symptoms of generalized anxiety. Dental statuses were heterogeneous in terms of the severity and accumulated dental treatment needs. The TADA population represented the lower socioeconomic range; 15% of patients had higher education levels, and half received social security benefits. All patients were referred to and started adapted dental treatment (phase 2).

CONCLUSIONS

TADA treatment approach appears acceptable and potentially beneficial for patients with odontophobia and dental anxiety related to psychological trauma experiences. The findings suggest that further research, including larger controlled studies, is warranted to validate these preliminary outcomes.

TRIAL REGISTRATION

The study was approved by the regional ethical committee in Norway (REK-Midt: 488462) and by the Data Protection Board at Møre and Romsdal County Authority.

Jeet Wheel Scale: A Novel Tool for Evaluation of Dental Anxiety in Children

Background

One of the major concerns of the current era is dental anxiety in Pediatric Dentistry. Kids are very well adapted to emojis or emoticons nowadays, and they represent emotions or moods better than a cartoon picture. Therefore, this study was conducted to evaluate a newly designed anxiety rating scale. The Jeet Wheel Scale (JWS) uses emoticons and colors to assess the anxiety or mood of the child during the first visit of the child.

Aim

The aim was to establish the novel anxiety rating scale and compare it with the Venham Picture Test (VPT) and Facial Image Scale (FIS).

Materials and methods

The study included 100 healthy children aged 4-8 years, and their dental anxiety was assessed using the JWS, VPT, and FIS at their first dental appointment, along with their scale preference.

Results

The mean and standard deviation of anxiety scores measured using the FIS, VPT, and JWS were 1.67 ± 0.88, 1.99 ± 1.17, and 2.79 ± 1.35, respectively. Among the scales used, a significant difference was observed. A strong correlation was observed with the Pearson correlation test. The results indicated a strong correlation (0.863) between the JWS and VPT, and a strong correlation (0.802) between the JWS and the FIS. Based on the above observations, it could be confirmed that the JWS has high validity. Children preferred the JWS over the other two established scales.

Conclusion

The JWS was found to be more efficient for assessing dental anxiety in children.

How to cite this article

Chakraborty S, Jana S, Dey B, et al. Jeet Wheel Scale: A Novel Tool for Evaluation of Dental Anxiety in Children. Int J Clin Pediatr Dent 2024;17(8):898-902.

Effect of age-related extended high frequency hearing loss on the subjective impressions of dental drill noise

Fear and anxiety among patients are sometimes evoked in dental clinics due to the sound of dental drills. This study aimed to explore the impact of age-related hearing loss in the extended high frequency (EHF) range above 8 kHz on individuals' subjective discomfort towards dental drill noise. After measuring pure-tone audiometric thresholds at both conventional and extended high frequencies, we used a psychoacoustic approach to evaluate subjective impressions of four dental drill sound stimuli, which featured varying frequency components, in 62 participants (aged 12-67 years). We found a significant decrease in hearing sensitivity within the EHF range as age increased, with notable differences in hearing thresholds at 14 kHz between teenage and older adults exceeding 65 dB. Furthermore, significant differences were observed between younger and older (above 40 years) participants in the subjective impressions of dental drill noise, emphasizing age as a critical factor in the perception of high frequency components. Consequently, age may influence the unpleasantness of dental drilling noise. Compared to older individuals, young participants may exhibit increased fear of dental procedures owing to physiological factors. These results underscore the need for age-appropriate noise control strategies in dental clinics to mitigate anxiety and improve patient comfort.

Dental treatments under sedation-analgesia in patients who are unable to collaborate: a prospective observational study

Background

Excessive fear of dental procedures leads to disruptive behavior during dental examinations and treatments. Dental examinations and treatments of these patients usually require additional techniques, such as sedation. The most commonly used techniques are inhalation of nitrous oxide, infusion of propofol with fentanyl, and premedication and infusion of midazolam.

Methods

A prospective observational epidemiological study was conducted on patients who required sedoanalgesia techniques for dental exploration and procedures. The reasons for the inability of patients to cooperate (excessive fear or intellectual disability), age, sex, weight, systemic pathology, oral pathology, treatment performed, time of intervention, anesthetic technique performed, and occurrence of complications were recorded.

Results

In total, 218 patients were studied. Sixty-five patients came for fear of dental treatment and 153 for presenting with a diagnosis of intellectual disability and not collaborating in the treatment with local anesthesia. The average age of all patients was 30.54 ± 17.30 years. The most frequent oral pathologies found in patients with excessive fear were tartar (6.8%) and wisdom teeth (6.4%), followed by missing teeth (5%). In patients with disabilities, a combination of tartar and cavities appeared most frequently (41.3%), followed by cavities (15.6%). The most frequently used sedoanalgesia technique was the infusion of propofol with fentanyl in both groups of patients, followed by nitrous oxide.

Conclusion

The combination of propofol and fentanyl was the most frequently used alternative in patients who were unable to collaborate because of intellectual disability or carry out longer or more complex treatments. Inhaled nitrous oxide and midazolam were the sedative techniques of choice for simpler oral treatments, such as tartrectomies, shallow obturations, and shorter interventions, or in younger patients.

Global prevalence of early childhood dental fear and anxiety: A systematic review and meta-analysis

OBJECTIVE

The objective of this review is to determine the global prevalence of dental fear and anxiety (DFA) in early childhood and identify its related factors.

METHODS

The systematic review utilized three common English-language databases (PubMed, EMBASE, and Web of Science). Two independent researchers performed a systematic search to include observational studies on young children published from 2000 to 2023. They extracted information on prevalence of DFA, assessment tools used, study sites, respondents, and children's dental visit experiences.

RESULTS

A total of 2,895 studies were identified, and 25 studies met the inclusion criteria for analysis. The pooled prevalence of DFA among 2- to 6- year-old children was estimated to be 30 % (95 % CI=25, 36). Children without dental visit experience (OR=1.37, 95 % CI=1.18, 1.59) and children with caries experiences (OR=1.18, 95 % CI=1.09, 1.27) had higher odds of experiencing DFA compared to those with dental visit experience or caries-free status. The most commonly used assessment tools in the included studies were the Frankl Behaviour Rating Scale (32 %, 8/25), Children's Fear Survey Schedule-Dental Subscale (20 %, 5/25), and Dental Anxiety Question (20 %, 5/25).

CONCLUSIONS

This systematic review reveals that approximately one-third of young children globally experience DFA. Children who lack dental visit experience or have caries experiences are at increased risk of DFA. Clinicians can use this information to make informed decisions regarding dental care provision for young children.

CLINICAL SIGNIFICANCE

This study provides comprehensive information on the global prevalence of dental fear and anxiety and its associated factors in early childhood. The findings can assist clinicians in understanding and addressing DFA in their dental care approach for young children.

REGISTRATION

PROSPERO (CRD42023446464).

Impact of high-speed handpiece noise-induced dental anxiety on heart rate: analyzing experienced and non-experienced patients - a comparative study

BACKGROUND

Dental anxiety is very much common among the patients and could be due to different factors like the behavior of the dentist, past experiences, Needle phobia, or word of mouth from other patients. According to recent studies, a strong association between sound and anxiety has been found, so this observational study has been conducted to find out the link between the activation of anxiety with the sound of a handpiece between experienced patients, who have already gone through the dental treatments and non-experienced patients.

METHODS

Total of 297 participants were part of this study. These participants were divided into 2 groups according to the experienced and non-experienced dental patients. The researcher first filled out the CORAH Dental Anxiety Scale (DAS) form to mark the anxiety level of the patients, and then noted the readings of the heart rate in 3 intervals which were before during, and after the treatment with the pulse oximeter. Later the data was analysed using the SPSS independent t-test.

RESULTS

Results show that patients in group 1 who have gone through the dental treatment before were less anxious and had a lesser effect on their heart rate than the patient who were having the treatment for the first time who were in group 2. Another interesting factor was noticed that in both the groups female were found to be more anxious than male participants. Participants with younger age were found to be more anxious than older age patient in both groups CONCLUSIONS: The sound of the handpiece can provoke anxiety in the patient, affecting the heart and increasing the heart rate. Participants who were experienced were found to be less anxious than the participants who were inexperienced.

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.

Evaluation of Children's Anxiety Level in Relation to a Dental Visit/Treatment and Their Parents' Dental Fear

The patients' fear of the dentist plays an important role in the everyday life of a dentist. The anxiety level of children in relation to dental treatment/visits and to their parents' dental fear was evaluated in three different centers. Assessments of a modified CFSS-DS (mCFSS-DS) were performed by questionnaire with 60 children and their parents. Children's dmft/DMFT scores, age and gender were evaluated in relation to the parents' perception of their child's anxiety levels. For statistical evaluation, Kruskal-Wallis and Wilcoxon tests as well as Spearman's correlation coefficient (Spearman) were used. The significance level was set at 0.05. There were no significant differences regarding children's mCFSS-DS between the three centers (p = 0.398, Kruskal-Wallis). The parents' mCFSS-DS scores correlated significantly with their children's mCFSS-DS scores (p = 0.004, Spearman). However, the mean mCFSS-DS score of the children was significantly higher than the mean score of parents' perception of their child's anxiety (p = 0.000, Wilcoxon). The age of the child had an influence on the mCFSS-DS score (p = 0.02, Kruskal-Wallis) but neither the children's gender (p = 0.170, Kruskal-Wallis), nor the dmft/DMFT showed an impact (p < 0.725, Spearman). Although a positive correlation was found between the results of the children's and parents' questionnaire, many parents underestimated the anxiety level of their children.

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.

Application of Bispectral Index System (BIS) Monitor to Ambulatory Pediatric Dental Patients under Intravenous Deep Sedation

Purpose Intravenous sedation has been well accepted to allow dental restoration in uncooperative children while avoiding aspiration and laryngospasm; however, intravenous anesthetics such as propofol may lead to undesired effects such as respiratory depression and delayed recovery. The use of the bispectral index system (BIS), a monitoring system reflective of the hypnotic state, is con-troversial in the reduction in the risk of respiratory adverse events (RAEs), recovery time, the in-travenous drug dosage, and post-procedural events. The aim of the study is to evaluate whether BIS is advantageous in pediatric dental procedures. Methods A total of 206 cases, aged 2-8 years, receiving dental procedures under deep sedation with propofol using target-controlled infusion (TCI) technique were enrolled in the study. BIS level was not monitored in 93 children whereas it was for 113 children, among which BIS values were maintained between 50-65. Physiological variables and adverse events were recorded. Statistical analysis was conducted using Chi-square, Mann Whitney U, Independent Samples t and Wilcoxon signed tests, with a p value of <0.05 considered to be statistically significant. Results Although no statistical significance in the post-discharge events and total amount of propofol used was observed, a clear significance was identified in periprocedural adverse events (hypoxia, apnea, and recurrent cough, all p value < 0.05) and discharge time (63.4 ± 23.2 vs. 74.5 ± 24.0 min, p value < 0.001) between these two groups. Conclusions The application of BIS in combination with TCI may be beneficial for young children undergoing deep sedation for dental procedures.

A Promising Tool For Overcoming Dental Anxiety

Researchers in Philadelphia, Pennsylvania, are testing a cognitive behavioral intervention with the aim of removing a common obstacle to dental care.

Pain, discomfort, and functional impairment after extraction of primary teeth in children with palatally displaced canines - a randomized control trial comparing extraction of the primary canine versus extraction of the primary canine and the primary first molar

CONCLUSION

Primary canines and first molars can be extracted in a way that is associated with relatively low levels of pain and discomfort during and after the procedures. Double extractions induced more pain and discomfort than single extractions, which should be accounted for in the treatment planning.

MATERIAL AND METHODS

Twenty-eight children, aged 9.5-14 years with displaced permanent maxillary canines were randomly assigned for extraction of the primary canine only or the primary canine and the primary first molar. Pain and discomfort were rated on visual analogue scales, and influence on daily activities was assessed by a questionnaire that has been previously tested for reliability and validity. Differences between groups were assessed by independent samples t-tests, Mann-Whitney U-tests or the Fisher's exact test.

OBJECTIVE

To assess pain, discomfort, and functional impairment in children experiencing extraction of primary canine or primary canine and primary first molar as an interceptive treatment for palatally displaced permanent canines.

RESULTS

Tooth extraction was associated with low levels of pain and discomfort on a group level. Extraction of both the canine and the first molar was associated with significantly more pain and discomfort than was the extraction of the canine only. Extractions were associated with chewing problems among one-third to half of the children, otherwise, few children reported any jaw impairment after extraction.

The complexity of dental anxiety and its association with oral health-related quality of life: An exploratory study

This study aimed to explore the factors associated with oral health-related quality of life (OHRQoL) in a sample with high dental anxiety. Data were obtained from 107 patients attending a therapeutic treatment program for people who have experienced abuse and for those with dental phobia in Norway. Patients completed questionnaires, including the Index of Dental Anxiety and Fear, the Anxiety subscale of the Hospital Anxiety and Depression Scale, and the Oral Impacts on Daily Performance scale, measuring OHRQoL prior to treatment. The various measurement instruments were evaluated psychometrically, and the variables associated with OHRQoL were explored using hierarchical multiple regression. Symptoms of dental anxiety and general anxiety were high, while OHRQoL was poor. Dental anxiety, higher age, higher number of years since the last dental treatment, and higher general anxiety were discernibly associated with lower OHRQoL. The strongest association was found between general anxiety and OHRQoL. In conclusion, several factors were associated with OHRQoL in a sample with high dental anxiety, suggesting a complex picture of dental anxiety. When treating patients with high dental anxiety, dental practitioners should be aware that there may be factors complicating the therapeutic setting, such as general anxiety.

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.

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.

Oral Care Knowledge, Attitudes, and Practices of Black/African American Caregivers of Autistic Children and Non-Autistic Children

Oral health is a vital component of overall health. Children from underserved, minoritized populations (i.e., Black/African Americans, autistic children) are at even greater risk for experiencing oral health disparities. This study aims to illuminate the oral health knowledge, attitudes, and practices of Black/African American caregivers of autistic and non-autistic children. Black/African American caregivers of children (4-to-14 years) on the autism spectrum (n = 65) or not on the autism spectrum (n = 60), participated in a survey, with input from literature reviews, interviews, previous research, and reviews by experts. Caregivers demonstrated basic knowledge of oral health with significantly lower scores for caregivers of autistic children. Caregivers care about oral health and would like to increase their knowledge. Significant differences in oral care practices were found between the autistic and non-autistic groups. Caregivers reported they can access dental services with relative ease, including finding their child a dentist, scheduling a dental appointment, and accessing transportation (personal or public) to attend the visit. Black/African American caregivers of autistic children and children without autism seem to have foundational knowledge about oral health and basic practices; however, they are interested in learning more. Therefore, tailored oral health education programs may help mitigate oral health disparities for Black/African American families.

Evaluation of efficacy of computer-controlled local anaesthetic delivery system vs traditional injection system for minor pediatric surgical procedures in children

Background

One of the biggest barriers to successful delivery of quality dental care to paediatric patients is fear related to injection of local anaesthetic. This study aimed to evaluate the efficacy of a computer-controlled local anaesthetic delivery (CCLAD) system when compared with a traditional anaesthetic injection. The two systems were compared with respect to reducing pain-related fear and anxiety.

Methods

Eighty children in the age group between 6 and 13 yrs requiring minor paediatric dental procedures on both sides of the dental arch were administered local anaesthesia using a CCLAD system and traditional injection system in two consecutive treatment sessions. The anxiety and fear related to the injection before and after the procedure was evaluated using Children's Fear Survey Schedule - Dental Subscale (CFSS-DS). The pain perception was evaluated using Wong-Bakers pain scale.

Results

The percentage wise distribution of pain rating as filled out by the subjects after being administered the local anaesthesia using CCLAD system, and the conventional injection system showed that pain levels experienced by the subjects was lower with the CCLAD injection system than with the conventional injection system. The comparison of CCLAD and conventional groups pretest and post-test CFSS-DS scores showed significantly lower values for CCLAD group indicating lower anxiety levels.

Conclusion

This study showed that the CCLAD system could be an useful alternative in administration of local anaesthesia. However, its effectiveness could be tested when used in highly anxious children. The disadvantages of CCLAD systems is that it requires a longer time during administration and cost.

Dental fear and anxiety in Asian youths: response components and inducing stimuli

OBJECTIVES

This study estimated the prevalence of dental fear/anxiety (DFA) and phobia in Asian youths and investigated the fear/anxiety response components and triggers for those with DFA.

MATERIALS AND METHODS

A convenience sample of youths, aged 17 to 24 years old, was recruited from a local polytechnic. The Index of Dental Anxiety and Fear-4C + (IDAF-4C +) was employed to assess the occurrence of DFA (IDAF-4C) and phobia (IDAF-P) as well as to ascertain fear/anxiety-inducing stimuli (IDAF-S). Psychological distress was determined with the Patient Health Questionnaire-4 (PHQ-4). Sociodemographic, IDAF-4C + , dental attendance patterns, and PHQ-4 data were gathered electronically. Statistical analyses were conducted with chi-square, Kruskal-Wallis, and relevant post hoc tests (α = 0.05).

RESULTS

A total of 215 participants were enrolled (mean age of 18.9 ± 2.0 years; 87.4% women). Of these, 12.6/6.0% had moderate-to-high (MH)/high-to-extreme (HE) DFA and 0.9% experienced dental phobia. Significant differences in scores were observed between the HE/MH and no-to-moderate (NM) groups for all IDAF-4C components. Apart from the cost of dental treatment, IDAF-4S scores varied significantly among the three DFA groups. The two most highly rated DFA stimuli were painful/uncomfortable procedures and needles/injections for the HE group, while they were needles/injections and the cost of dental treatment for the MH and NM groups.

CONCLUSIONS

Moderate-to-extreme DFA existed in 18.6% of the Asian youths examined. The emotional and physiological components of the IDAF-4C appear to contribute more to the DFA response. Dental pain including needles/injections and the cost of dental treatment troubled Asian youths the most.

CLINICAL RELEVANCE

DFA is a common problem among Asian youths, and understanding its extent, nature, and triggers is central for effective interventions.

The Effect of Dental Treatments in Caries Management on Stress and Salivary Protein Levels

A great burden is put on healthcare systems by dental caries and understanding patients’ treatment needs is of utmost importance. The aim of this pre−post study was to assess dental anxiety and the psychological stress induced by two different types of dental treatment (prophylaxis and cavity preparation), by combining psychometric evaluations with salivary biomarkers, in a group of 28 schoolchildren presenting in a university clinic. Pre- and post-treatment unstimulated whole saliva was collected and levels of cortisol, alpha-amylase (sAA) and total protein content were measured. The State−Trait Anxiety Inventory for Children and the Frankl Behaviour Rating Scale (FBRS) were applied. Statistical analysis was performed using the Stata/IC 16 (StataCorp) programme. All salivary parameters showed strong positive correlations between pre- and post-treatment levels. Post-treatment, salivary cortisol decreased (p = 0.008, paired t-test), sAA did not change significantly (p = 0.572, sign test), while the sAA/cortisol ratio (AOC) increased (p = 0.036, sign test). There were no correlations between state and trait anxiety levels. State anxiety scores registered significantly higher values for children with an FBRS score of 3 compared with a score of 4 (p < 0.001, unpaired t-test). The post-treatment decrease in the salivary cortisol level was higher for prophylaxis compared with the cavity preparation group (p = 0.024, t-test). These results demonstrate that sAA and cortisol levels are altered differently by psychological stress induced by two different types of dental treatment.

Dentist Empathic Accuracy Is Associated With Patient-Reported Reassurance

OBJECTIVES

The aim of this work was to determine dentists' ability to accurately estimate patients' anxiety level during dental treatment (ie, "empathic accuracy") and to determine the strength of the association between empathic accuracy and patient-reported reassurance.

METHODS

A cross-sectional study was conducted amongst 177 adult patients who underwent different invasive dental procedures (ie, extractions or procedures requiring injections and drilling) performed by 10 different dentists from 3 dental offices in the Netherlands. Patients reported their anxiety level during treatment and the extent to which they felt reassured by the dentist using a visual analogue scale (VAS). Simultaneously, the dentists estimated patients' anxiety level. Empathic accuracy was calculated as an absolute difference between patient-reported anxiety (100-point VAS) and dentist estimation of anxiety (100-point VAS).

RESULTS

Agreement between dentists' assessment of patients' anxiety and patient-reported anxiety proved good, intraclass correlation coefficient (177) = 0.63; 95% confidence interval [CI], 0.53-0.71. A small to medium-sized positive correlation, r (177) = 0.15; 95% CI, 0.00-0.29, was found between dentists' empathic accuracy and patient-reported reassurance. A negative correlation was found between empathic accuracy and patients' anxiety scores, r (177) = -0.23; 95% CI, -0.38 to -0.09.

CONCLUSIONS

Given that greater empathic accuracy was associated with higher patient-reported reassurance during treatment, training young dental professionals in empathic accuracy might help patients feel reassured. Importantly, our results also suggest that with elevated levels of patient anxiety it is increasingly challenging for dentists to recognise this emotion, and thus support the patient in anoptimal manner.

Patient and Caregiver Perceptions of Animal Assisted Activity in Orthodontics

Dental anxiety affects up to 21% of children and 80% of adults and is associated with lifelong dental avoidance. Animal assisted activity (AAA) is widely used to reduce anxiety and pain in medical settings and has promise in dentistry. The primary objective of this study was to evaluate caregiver and patient perceptions of canine AAA in orthodontics. A cross-sectional survey consisting of pre-tested and validated questions was conducted (n = 800) including orthodontic patients (n = 352 minors, n = 204 adults) and parents/caregivers (n = 244) attending university orthodontic clinics. In this study, AAA and dog therapy were not used or tested for dental anxiety management. More than a third of orthodontic patients (37%) had moderate or greater anxiety related to care. Participants believed that therapy animals would make dental experiences more enjoyable (75%) and reduce anxiety (82%). There was little to no concern expressed regarding cleanliness (83%), allergies (81%), and safety (89%) with a therapy animal in dental settings. Almost half of the participants would preferentially select an orthodontic office offering AAA. In light of the COVID-19 pandemic, we assessed whether perceptions of AAA changed before and after the shutdown of dental offices, with no significant differences. Across patients and caregivers, the responses support the use of AAA in orthodontic settings with minimal concerns.

Dental Anxiety and Oral-Health-Related Quality of Life among Rural Community-Dwelling Older Adults

Aim: This study aimed to investigate the association between dental anxiety (DA) and oral-health-related quality of life (OHRQoL) among rural community-dwelling older adults. Methods: A cross-sectional descriptive study was conducted among 390 rural community-dwelling older adults attending outpatient clinics of the Damanhur National Medical Institute during the year 2021. Three instruments were used: a demographic and clinical data structured interview schedule, Modified Dental Anxiety Scale (MDAS), and the Oral Health Impact Profile (OHIP-5) questionnaire. All statistical analyses were considered significant at a p-value of ≤0.001. Results: The main results showed that the prevalence of DA among participants was 90.5%, and 66.9% of the studied elderly population were either extremely (phobic) or very anxious. Moreover, a significant association was found between older adults’ DA and their OHRQoL (p ˂ 0.001). Conclusions: It was concluded that DA represents a common problem among rural community-dwelling older adults and is a predictor for poor OHRQoL. Raising community awareness about the importance of oral health and implementing measures to avoid DA through specialized community campaigns is recommended, particularly in rural areas.

Behavioral Modification of an Uncooperative Preschool Child with Sickle Beta Thalassemia Disease in a Dental Clinic: A Case Report

Background:

Treating medically compromised pediatric patients with dental anxiety can be challenging, especially when general anesthesia and sedation are not an option. This paper reported a case of an uncooperative preschool child who was medically compromised and presented in the dental clinic with Severe-Early-Childhood-Caries (S-ECC). The dental behavior management of such a case was not previously discussed in the literature.

Case Presentation:

This paper explains the dental management and behavior modification carried out for a 5-year-old male child who was diagnosed with sickle beta thalassemia disease (Sβ-thalassemia), S-ECC, had a negative dental behavior, and was successfully and efficiently treated under a dental setting. The patient presented with his mother, who was concerned about her child’s decayed teeth and sought dental treatment as soon as possible to avoid any risk of infection. Dental examination revealed multiple dental caries and high caries risk. The patient’s behavior can be classified as definitely negative with high level of anxiety. The mother showed permissive parenting and the father exerted an authoritative parenting style. Dental management focused mainly on child behavioral modification via utilizing the difference between the parenting styles. Middle way of treatment, the child showed behavioral improvement, which was progressing toward the end of the treatment. Teeth were successfully restored with composite and metal crowns.

Conclusion:

With several behavior management techniques and understanding the parenting styles, the patient's behavior improved, and the treatment plan was successfully used on a dental chair without the need for more advanced management under general anesthesia.

Assessment of psychological changes in young children during dental treatment: Analysis of the autonomic nervous activity and electroencephalogram

BACKGROUND

Understanding the emotional changes in children during dental treatment is necessary for providing stress-free care.

AIM

To objectively assess the stress associated with dental treatment in children, based on the autonomic nervous activity and the electroencephalogram (EEG).

DESIGN

Twenty-two children aged 4-9 years were recruited from outpatients of a paediatric clinic. Electrocardiogram and EEG were recorded throughout the treatment to analyze the autonomic nervous activities and the powers of brain waves, respectively. Changes in these measurements during each treatment process were evaluated in two age groups: 4-6 years and 6-9 years.

RESULTS

Elevations in sympathetic activities accompanied by decreased parasympathetic activities induced by stress were observed during rubber dam setting (RD) in the age group of 4-6 years and during infiltration anesthesia (IA), RD, and cavity preparation with a dental turbine (CP-T) in the age group of 6-9 years. Stress-related beta wave increments in EEG were observed during IA and CP-T in the age group of 6-9 years but not in the age group of 4-6 years.

CONCLUSION

Monitoring the autonomic nervous activities during treatments is useful in assessing stresses in a wide age of young children, whereas EEG monitoring is applicable only to children older than 6 years.

Dental fear in school children and young adults attending public dental health care: prevalence and relationship to gender, oral disease and dental treatment; trends over 40 years

Purpose

To study prevalence of dental fear and the relationship to gender, oral disease and dental treatment between 1973 and 2013 in school children and young adults attending public dental health care.

Methods

Every ten years from 1973 to 2013 random samples of about 100 individuals in each of the age groups 10, 15 and 20 years took part in a repeated cross-sectional study based on clinical parameters and a questionnaire. Dental fear was estimated by the question: “What do you feel at the prospect of an appointment with a dentist?”. 75–99% of the samples answered the question. Agreement to at least one of the alternative answers: ill at ease, frightened and sick defined dental fear. Frightened and/or sick indicated severe dental fear. The prevalence of caries, gingivitis and number of filled tooth surfaces were calculated. Chi-square tests were used to show differences in proportions between groups and linear regression to show trends over time.

Results

Prevalence of dental fear declined in all age groups over time. In the 20-year olds dental fear was found in 29% of the sample and severe dental fear in 12% of girls and 5% of boys in 2013. Individuals with dental fear had higher mean caries prevalence and number of filled tooth surfaces compared with individuals without dental fear.

Conclusions

This 40-year time trend study showed a reduction in dental fear prevalence in school children and young adults offered regular public dental health care based on prevention and a psychological approach. The prevalence of dental fear was still high in 2013 despite a significant decline in caries during the study period. Further improvements in the psychological approach when treating children are thus needed.

The in-practice prevention programme: an example of flexible commissioning from Yorkshire and the Humber

Introduction An In-Practice Prevention (IPP) programme was developed by the Local Dental Network in the North Yorkshire and the Humber area in England in response to an oral health needs assessment. The underpinning logic model drew on a flexible commissioning approach and aimed to incentivise dental teams with NHS contracts to promote the delivery of prevention. This used care pathways that involved the whole dental team and was cost-neutral.Aim The programme was evaluated using realist methodology to identify 'what works, in which circumstances, how and for who?'.Design Realist evaluations are explanatory in nature and attempt to understand the factors that appear to influence the success (or not) of an intervention, rather than demonstrating causality.Methods and results Following a review of the pertinent literature, semi-structured interviews and focus groups, five theory areas were considered to be critical to the delivery of IPP. In order of stated priority, these were: 1) clinical leadership; 2) 'skill mix'; 3) financial incentives; 4) institutional logic/practice culture; and 5) behaviour change.Conclusion The results appear to show that clinically-led programmes could offer value to dental commissioners within a flexible commissioning model, although this would need to be further tested using an experiment design.

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.

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.

Translation and Validation of the Short Form of the Fear of Dental Pain Questionnaire in China

The short form of the Fear of Dental Pain Questionnaire (s-FDPQ) is a validated measure developed to screen patients for their fear of pain associated with dental procedures. As there is a high prevalence of dental fear/anxiety in Chinese adults, the primary aim of our study was to translate the s-FDPQ into standard Mandarin and explore its reliability and validity with Chinese adults. The second aim of our study was to explore fear of dental pain (FDP) scores in relation to dental attendance, anxiety and gender. We translated the s-FDPQ using the forward-backward method. It was completed by 480 Chinese adults alongside the Modified Dental Anxiety Scale (MDAS; Chinese version) to test convergent validity. 109 participants completed the s-FDPQ again 14 days later to evaluate test-retest reliability. The Chinese s-FDPQ (s-CFDPQ) was internally consistent (alpha = 0.87) and demonstrated convergent validity (r = 0.73 when correlated with the MDAS). Test-retest reliability was good (ICC = 0.86). Individuals who had never attended the dentist (22%) had higher FDP scores than those that had, even if they were not dentally anxious. Also, females reported higher FDP scores (p < 0.001). These findings suggest that the s-CFDPQ is a reliable and valid measure for assessing fear of dental pain in Chinese adults. The s-CFDPQ could allow quick identification of individuals who are fearful of dental pain who may require specialist attention.

The roles of disgust sensitivity and anxiety sensitivity in attentional bias in dental anxiety

Individuals with dental anxiety show biased attentional processing of threat- and dental-related information. Disgust sensitivity and anxiety sensitivity are both associated with dental fears and attentional biases. Whereas disgust sensitivity is generally associated with attentional avoidance (Armstrong et al., 2014), anxiety sensitivity may be associated with attentional engagement (Keogh et al., 2001a). Elucidating the role of these constructs in dental anxiety-relevant attentional biases could inform theoretical models and/or intervention recommendations. Participants (N = 51) with high dental anxiety completed a Posner paradigm to assess attentional biases to dental versus neutral stimuli. We examined whether disgust sensitivity and anxiety sensitivity moderated degree of attentional bias. Results indicated that both disgust sensitivity (mutilation subscale) and anxiety sensitivity (physical concerns subscale) statistically moderated degree of attentional bias at trend level, and in opposite directions. Simple effects analyses further indicated that disgust sensitivity regarding mutilation was associated with less attentional bias toward dental relative to neutral stimuli, potentially indicating attentional avoidance, and remained so when adjusting for anxiety sensitivity. In contrast, simple effects analysis indicated that anxiety sensitivity regarding physical concerns was not associated with magnitude of attentional bias. If replicated, findings highlight the potential role of disgust in dental anxiety.

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.

To Compare and Analyze the Potency of two Topical Anesthetic Gels in Reducing Inferior Alveolar Injection Pain in Children of 8-12 Years: A Double-Blinded Clinical Trial

Aim:

To compare and analyze the clinical adequacy of two topical anesthetic gels, Precaine (8% lidocaine + 0.8% dibucaine) and Precaine B (20% benzocaine) in children before intraoral local anesthetic injections.

Materials and Methods:

This clinical study included thirty children who needed an inferior alveolar nerve block. They were divided into three groups: Group A: Precaine topical gel group, Group B: Precaine B topical gel Group, Group C: no anesthetic topical gel group (control group). These two effective topical gels were applied before giving intraoral local anesthesia, and afterward, the child's pain response was surveyed utilizing the Wong-Baker Faces Pain Rating Scale. The scores obtained were subjected to statistical analysis.

Results:

Intergroup comparison showed a significant mean difference between the control group and Precaine group (P > 0.05) as well as Precaine B group (P > 0.05). However, there is no significant difference obtained between Group A and Group B (P < 0.05).

Conclusion:

It is psychologically and clinically beneficial to apply a topical anesthetic agent before injecting any intraoral anesthesia. In this study, both anesthetic gels showed a nonsignificant difference in reducing inferior alveolar injection pain, but Precaine B shows more promising results than Precaine.

Magnification of fear and intention of avoidance in non-experienced versus experienced dental treatment in adults

BACKGROUND

Dental fear is associated with the experience of prior dental treatment and avoidance of dental visits. It remains unclear if individuals show an intention of avoidance (IA) towards treatments that they have not received (i.e., non-experienced dental treatment). The study aims to investigated (a) if individuals showed an increased fear and IA to non-experienced, compared to experienced dental treatment, and (b) if fear and IA to non-experienced treatment is associated with dental anxiety.

METHODS

Fear/IA of 12 common conditions of dental treatment of 402 adults were investigated. If subjects have experienced the condition, fear and IA were assessed based on subjects' prior experience (i.e., ExpFear/ExpIA). If they have not experienced the condition, fear and IA were assessed based on their anticipation (i.e., NExpFear/NExpIA). Trait dental anxiety was assessed using the Index of Dental Anxiety and Fear (IDAF-4C+).

RESULTS

(A) NExpFear and NExpIA were significantly higher than ExpFear and ExpIA, respectively. (B) The IDAF-4C+ scores are positively correlated with NExpFear/NExpIA and negatively correlated with the magnification of fear (i.e., the discrepancy in the fear/IA of non-experienced vs. experienced conditions). (C) The condition 'extraction of a wisdom tooth' and 'root canal treatment' showed the highest ratings on NExpFear.

CONCLUSIONS

Individuals may develop a high degree of fear and IA of the treatment they have not received. Trait dental anxiety plays a key role in the fear of non-experienced treatment.

Efficacy of aromatherapy on dental anxiety: A systematic review of randomised and quasi-randomised controlled trials

OBJECTIVES

To evaluate the efficacy of aromatherapy on dental anxiety.

METHODS

A detailed protocol was registered a priori (PROSPERO: CRD42019141093). PubMed, EMBASE, CDSR, CENTRAL, CNKI and grey literature databases were searched from inception to 10 January 2020. Randomised controlled trials (RCTs) and quasi-randomised controlled trials (CCTs) that examined the effects of aromatherapy on dental anxiety, compare to either negative control (i.e. no aromatherapy) or other positive control approaches (e.g. music), were included. The risk of bias of the selected studies was evaluated using the Cochrane Collaboration's tool and ROBINS-I, while the certainty of evidence was assessed using GRADE. A narrative synthesis was performed, rather than meta-analysis, due to the high level of heterogeneity across studies.

RESULTS

Eleven RCTs and six CCTs were included. The risk of bias was identified as either high or unclear in RCTs, and moderate to serious in CCTs. Performance bias and detection bias were the most prevalent in RCTs, followed by selection bias and reporting bias. As to CCTs, greater risk of bias was found in the selection of participants into the study and in the measurement of outcomes. Based on the selected studies, the most commonly used aromatherapy for dental anxiety management was lavender fragrance, followed by orange. Compared to the negative control condition, aromatherapy might reduce the anxiety-related physiological parameters and psychometric rating, pain, and mood, alertness, and calmness compared to the negative control condition; and there might be no intergroup difference in such outcomes between aromatherapy and music. However, GRADEs of the relevant evidence were judged as low to very low.

CONCLUSIONS

Compared to the negative control condition, aromatherapy is more effective to reduce dental anxiety and has comparable effects on dental anxiety compared to music intervention; however, the certainty of evidence is relatively limited. Further high-quality randomised trials with robust study design and large sample size are warranted to confirm our findings and to confirm the role of aromatherapy in relieving dental anxiety.

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.

Hair Cortisol Concentrations Are Associated with Dental Anxiety during Pregnancy

Dental anxiety (DA) and hair cortisol concentrations (HCC) are associated with psychological symptoms and vary during pregnancy. We aimed to examine the association between HCC and DA at two points of pregnancy. Participants were pregnant mothers (n = 533) drawn from the FinnBrain Birth Cohort Study donating a hair sample at gestational week (gwk) 24 (n = 442) and/or at delivery (n = 176) and completed questionnaires on DA. Two groups, HCC1 and HCC2, treated as separate in the analyses, were formed according to the hair sample donation time i.e., gwk24 and delivery. 85 subjects were included in both groups. MDAS, EPDS, and SCL-90 were used to measure DA, depressive and anxiety symptoms, respectively, at gwk14 for the HCC1 group and gwk34 for the HCC2 group. The association between DA and HCC was studied with a binary logistic regression model, adjusted for anxiety and depressive symptoms, age, BMI, and smoking status. Individuals with high DA had lower HCC levels at gwk24 (OR = 0.548; 95% CI = 0.35–0.86; p = 0.009), but the association was not statistically significant at the delivery (OR = 0.611; 95% CI = 0.28–1.33; p = 0.216). The independent association between HCC and DA in pregnant women suggests that long-term cortisol levels could play a role in the endogenous etiology of DA. Further studies are however, needed.

Estimated prevalence of dental fear in adults: A systematic review and meta-analysis

OBJECTIVES

To systematically review the literature about: 'What is the global estimated prevalence of dental fear in adults?'.

DATA/SOURCES

Inclusion criteria were observational population-based studies reporting the prevalence or raw data of dental fear in adults (>18 years). Five electronic databases (Embase, PubMed, Scopus, Virtual Health Library and Web of Science) were searched without language restrictions up to March 2020. Two researchers independently performed the study selection, data extraction and quality assessment of the included studies. Risk of bias was performed using the Joanna Briggs Critical Appraisal Checklist for Prevalence and Incidence studies. The prevalence pooled estimates of dental fear were calculated using fixed- and random-effect models. Subgroup analyses were performed.

STUDY SELECTION

The search strategy identified 4,486 studies. After removal of duplicates (1,722), title and abstract screening (2,764) and full-text reading (108), 31 publications were deemed eligible for this systematic review. Three studies presented low risk of bias and 28 studies presented high risk of bias. A total of 72,577 individuals 18 years of age or older composed the sample of this systematic review. The global estimated prevalence of dental fear and anxiety (DFA), high DFA and severe DFA in adults were 15.3 % (95 %CI 10.2-21.2), 12.4 % (95 %CI 9.5-15.6) and 3.3 % (95 %CI 0.9-7.1), respectively. Subgroup analyses showed a higher prevalence of DFA, high DFA and severe DFA among women and younger adults. The instruments used to measure dental fear also affected its prevalence.

CONCLUSIONS

Dental fear and high dental fear are prevalent in adults worldwide, being more prevalent among women.

CLINICAL SIGNIFICANCE

Evidence suggests fear negatively impacts dental care pattern, clinical and subjective oral health conditions. A better knowledge of the global prevalence and the factors associated with this problem will allow that prevention or even behavior modulation strategies of the fearful individual's in dental setting being carried out.