Cognitive Behavioral Therapy for Children with Dental Anxiety: A Randomized Controlled Trial

Feasibility, acceptability, and perceived effectiveness of weighted blankets during paediatric dental care

BACKGROUND

Weighted blankets are one method to provide deep pressure touch sensations, which are associated with a calming effect on the nervous system. Weighted blankets have been reported to elicit a calming effect during stressful dental encounters and routine prophylactic visits in older adolescents and adults. Preliminary research suggests that weighted blankets are safe and feasible for children in both hospital and home settings; this, however, has not yet been examined in a paediatric dental environment.

AIM

To examine the feasibility, acceptability, and perceived effectiveness of a weighted blanket during paediatric dental care.

DESIGN

This cross-sectional study examined child, caregiver, and dentist-reported responses to survey questions asking about their experience with the weighted blanket during care (n = 20 each per child and caregiver group, n = 9 dentists).

RESULTS

The use of a weighted blanket is feasible, acceptable, and appropriate as reported by caregivers and dentists (means ≥ 4.70 on the Feasibility of Intervention, Acceptability of Intervention, and Intervention Appropriateness Measures). Few problems were described, and all groups overwhelmingly responded with enthusiasm, noted the blanket's potential for future use, and perceived that a weighted blanket improved care (means ≥ 4.10).

CONCLUSIONS

Study findings support the feasibility and acceptability of using a weighted blanket during a routine, noninvasive paediatric dental care.

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: Randomized Controlled Trial

BACKGROUND

Dental phobia (DP) and injection phobia (IP) are common in children and adolescents and are considered some of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. As the availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking.

OBJECTIVE

This randomized controlled trial tests whether therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP or IP to receive dental treatment.

METHODS

We enrolled 33 participants (mean age 11.2, SD 1.9 y) whom a clinical psychologist had diagnosed with DP, IP, or both. After inclusion, participants were randomized to either ICBT (17/33, 52%) or a control group of children on a waitlist (16/33, 48%). ICBT was based on exposure therapy and comprised a 12-week at-home program combined with visits to their regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and 1 parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the outcome variables before treatment start and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview with a clinical psychologist. Our primary outcome measure was the Picture-Guided Behavioral Avoidance Test (PG-BAT), which assesses the ability to approach 17 dental clinical procedures, and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self-efficacy and levels of dental and injection anxiety. The children and their parents completed the questionnaires.

RESULTS

All participants underwent the 12-week follow-up. After treatment, 41% (7/17) of the participants in the ICBT group no longer met the diagnostic criteria for DP or IP, whereas all participants in the control group did (P=.004). Repeated-measure ANOVAs showed that ICBT led to greater improvements on the PG-BAT compared with the control group; between-group effect sizes for the Cohen d were 1.6 (P<.001) for the child-rated PG-BAT and 1.0 (P=.009) for the parent-rated PG-BAT. Reductions in our secondary outcomes-dental fear and anxiety (P<.001), negative cognitions (P=.001), and injection fear (P=.011)-as well as improvements in self-efficacy (P<.001), were all significantly greater among children in the ICBT group than in the controls. No participants reported adverse events.

CONCLUSIONS

ICBT seems to be an effective treatment for DP and IP in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; this therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02588079; https://clinicaltrials.gov/study/NCT02588079.

Prevalence and stability of blood-injection-injury phobia in childhood-A prospective community study in Norway

AIM

An individual with a blood-injection-injury (BII) phobia often avoids exposure to triggers, such as blood tests and clinic appointments, leading to potentially serious health complications. This population-based study examined the prevalence, stability and course of BII phobia in children and adolescents.

METHODS

The data came from the Trondheim Early Secure Study, conducted from 2007 to 2018. All children born in Trondheim, Norway, in 2003 and 2004 were invited to attend. Clinical interviews were conducted by trained personnel to assess BII phobia in 1042 children (51% female) every 2 years from 4 to 14 years of age. Latent growth curves and logistic regression analyses were used in the data analysis.

RESULTS

Just under 20% of the cohort experienced a BII phobia at least once, with no significant sex differences. The prevalence of BII phobias increased from 3% at 4 years of age and peaked at about 8% at 10 years of age, before levelling off. The two-year stability increased as 12-14 years of age approached.

CONCLUSION

The prevalence of BII was affected by age, but not sex. Early BII phobias often recede with time, but children may need treatment if they persist from 8 years of age.

Assessment of Different Distraction Behavioral Methods in Pediatric Dental Clinic: A Systematic Review

Dental anxiety is one of the main problems dentists may face during the treatment of pediatric dental patients; therefore, clinicians tend to perform different behavior management techniques to reduce dental anxiety in children. This review aimed to systematically compare and evaluate the published literature regarding the effects of distraction techniques on anxiety, pain perception, and patient experience during dental practice. A detailed electronic search was conducted on 3 databases including PubMed, Google Scholar, and Cochrane Library. The databases were searched for articles published in the English language between 2015 and 2022. Among 102 studies, 27 studies fulfilled the criteria of eligibility and were included in this study to be analyzed. Numerous approaches have been proposed for the reduction of dental anxiety, out of which the use of audio-visual aids and instruments, active distraction such as tablets, smartphones, and virtual reality glasses showed governance in decreasing the children's anxiety followed by cognitive and behavioral methods.

Rational thinking as a mediator of the relationship between mindfulness and dental anxiety

Dental anxiety causes people to postpone or refuse to go to the dentist, which further negatively impacts their quality of life and public health. Previous research has shown that mindfulness is inversely related to anxiety. However, little is known about the relationship between mindfulness and dental anxiety. The current research aimed to explore the relationship between mindfulness and dental anxiety and investigate the mediating role of rational thinking. Two studies were conducted. In study one, 206 Chinese participants completed questionnaires measuring trait mindfulness and dental anxiety (state, responding to a dental treatment scenario). In study two, 394 participants completed questionnaires measuring trait mindfulness, dental anxiety (trait), and rational thinking. The results for both studies showed that mindfulness is negatively correlated with dental anxiety. In study 1, each facet of mindfulness except Non-judging was negatively correlated with dental anxiety with Acting with Awareness having the strongest correlation, while in study 2, only Acting with Awareness was significantly negatively correlated with dental anxiety. Furthermore, rational thinking mediated the effect of mindfulness on dental anxiety. In conclusion, mindfulness is negatively related to both state and trait dental anxiety, and rational thinking mediates the relationship between mindfulness and dental anxiety. Implications of these findings are discussed.

Association between Intelligence Quotient Dental Anxiety and Oral Health-related Quality of Life in Children: A Cross-sectional Study

Background

Determining the intelligence quotient (IQ) grades of children help in managing dental anxiety (DA) and maintaining the good oral health-related quality of life (OHRQoL).

Aim

To assess the association between IQ, DA, and OHRQoL in children aged 10-11 years.

Design

This cross-sectional study was carried out among 202 children aged 10-11 years in the Southern part of Tamil Nadu, India. The IQ level, DA, and OHRQoL were measured using Raven's Coloured Progressive Matrices (RCPM), Children's Fear Survey Schedule-Dental Subscale (CFSS-DS), and Child Oral Health Impact Profile Short Form (COHIP-SF) 19, respectively. Chi-squared test and Spearman rank order correlation test were used for analysis.

Results

The results revealed a significant negative correlation (p < 0.05; r = -0.239) between IQ and OHRQoL. DA was negatively correlated with IQ (r = -0.093) and OHRQoL (r = -0.065), but it was not statistically significant. The gender-based comparison revealed no significant difference in the distribution of girls and boys within different grades of IQ levels (p = 0.74), DA (p = 0.29), and OHRQoL (p = 0.85).

Conclusion

Children with higher IQ showed low OHRQoL scores. DA was negatively correlated with IQ and OHRQoL.

How to cite this article

Asokan S, PR GP, Mathiazhagan T, et al. Association between Intelligence Quotient Dental Anxiety and Oral Health-related Quality of Life in Children: A Cross-sectional Study. Int J Clin Pediatr Dent 2022;15(6):745-749.

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.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

OBJECTIVES

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

SELECTION CRITERIA

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

AUTHORS' CONCLUSIONS

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

Factors Associated with Dental Fear and Anxiety in Children Aged 7 to 9 Years

The aim was to investigate changes in dental fear and anxiety (DFA) and verify factors associated with DFA in children. A longitudinal cohort study that included 160 children aged 7 years was carried out. A questionnaire was completed by parents at two time points and evaluated the immigrant background, maternal education, whether the child had ever had toothache, and whether the parents had dental fear. The oral clinical examination evaluated decayed, extracted, and filled primary teeth (deft). The children’s fear survey schedule dental subscale (CFSS-DS) was used to assess the dental fear of the children. Multilevel mixed-effects logistic regressions analyses were used. The CFSS-DS found that 7% of the children had dental fear at age 7 and mean CFSS-DS was 22.9. At 9 years of age, 8% reported dental fear and the mean increased to 25.4. Parental dental fear, experience of toothache, and report of painful dental treatment and caries development between 7 and 9 years of age were factors that were significantly related to development of DFA. There was a change in DFA between 7 and 9 years of age. Dental fear and anxiety is a dynamic process in growing individuals and is significantly related to painful symptoms and experiences of dental care as well as parental dental fear.

Are Technology-Based Interventions Effective in Reducing Dental Anxiety in Children and Adults? A Systematic Review

OBJECTIVES

The aim of this study was to evaluate the effectiveness of technology-based interventions for the treatment of dental anxiety in children and adults.

DATA SOURCES

A systematic search using relevant keywords was conducted in PubMed-Medline, EMBASE, PsycINFO, CINAHL, Scopus, and The Cochrane Library.

INCLUSION CRITERIA

Randomized controlled trials (RCTs) that compared technology-based interventions with inactive controls in the treatment of moderate to severe dental anxiety were included.

RESULTS

A total of seven RCTs were included in the review. These studies investigated the effectiveness of video modeling, computerized cognitive behavioral therapy, virtual reality exposure therapy, and distraction with music and audiovisual video material. Six studies examining video modeling, computerized cognitive behavioral therapy, virtual reality exposure therapy, and distraction (audiovisual) showed significantly greater reductions in dental anxiety than inactive controls in both children and adults. None of the included studies followed Consolidated Standards of Reporting Trials guidelines completely or reported sufficient data, thereby precluding a possible meta-analysis. Four out of seven included studies were assessed to be at high risk of bias.

CONCLUSIONS

A limited number of studies supported the effectiveness of technology-based interventions in the treatment of dental anxiety in children and adults.

CLINICAL SIGNIFICANCE

The quality of the methods of studies on the effects of technology-based interventions allows only limited inferences on the effects of these interventions. However, within the limitations of the systematic review, the results converge to suggest that technology-based interventions may be useful as an adjunct to standard dental care. High-quality RCTs are needed to determine the (relative) effectiveness of these interventions.

PROSPERO REGISTRATION NUMBER

CRD42017064810.

Cognitive behaviour therapy for anxious paediatric dental patients: a systematic review

BACKGROUND

There is a paucity of evidence about cognitive behaviour therapy in the management of dentally anxious children.

AIM

To systematically review evidence of the effectiveness of cognitive behaviour therapy for children with dental anxiety or dental phobia.

DESIGN

Clinical trial registries, grey literature, and electronic databases, including The Cochrane Library, EMBASE, PubMed, Scopus, Web of Science, LILACS/BBO, and PsycINFO, were searched (April 2018). The reference lists of relevant studies were hand-searched. Randomised controlled trials that evaluated the effects of cognitive behaviour therapy on dental anxiety or on acceptance of dental treatment in dental patients up to 18 years were included. Two trained and calibrated reviewers performed the study selection and risk of bias assessment. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Six studies with a total of 269 patients, aged 41 months to 18 years, were included. Cognitive behaviour therapy decreased level of anxiety compared to control groups and improved cooperation/behaviour, although the quality of the evidence was low.

CONCLUSIONS

Cognitive behaviour therapy produces better anxiety reduction than diverse behavioural management techniques but the evidence was of low quality and further studies in children are needed.

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental Anxiety: Open Trial

Background

Cognitive behavioral therapy (CBT) is an evidence-based method for treating specific phobias, but access to treatment is difficult, especially for children and adolescents with dental anxiety. Psychologist-guided Internet-based CBT (ICBT) may be an effective way of increasing accessibility while maintaining treatment effects.

Objective

The aim of this study was to test the hypothesis that psychologist-guided ICBT improves school-aged children’s and adolescents’ ability to manage dental anxiety by (1) decreasing avoidance and affecting the phobia diagnosis and (2) decreasing the dental fear and increasing the target groups’ self-efficacy. The study also aimed to examine the feasibility and acceptability of this novel treatment.

Methods

This was an open, uncontrolled trial with assessments at baseline, posttreatment, and the 1-year follow-up. The study enrolled and treated 18 participants. The primary outcome was level of avoidance behaviors, as measured by the picture-guided behavioral avoidance test (PG-BAT). The secondary outcome was a diagnostic evaluation with the parents conducted by a psychologist. The specific phobia section of the structured interview Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) was used. Other outcome measures included level of dental anxiety and self-efficacy. The ICBT, which employed exposure therapy, comprised 12 modules of texts, animations, dentistry-related video clips, and an exercise package (including dental instruments). Participants accessed the treatment through an Internet-based treatment platform and received Web-based guidance from a psychologist. Treatment also included training at dental clinics. Feasibility and acceptability were assessed by measures of engagement, adherence, compliance, completed measures, patient and parent satisfaction scale, and staff acceptability.

Results

The level of avoidance (according to the primary outcome measure PG-BAT) and dental anxiety decreased and self-efficacy increased significantly (P<.001), within-group effect sizes for both the primary outcome (Cohen d=1.5), and other outcomes were large in the range of 0.9 and 1.5. According to K-SADS-PL, 53% (8/15) of the participants were free from diagnosable dental anxiety at the 1-year follow-up. At the 1-year follow-up, improvements were maintained and clinically significant, with 60% (9/15) of participants who had been unable to manage intraoral injection of local anesthetics before ICBT reporting having accomplished this task at a dental clinic. The target group showed improvement in all the outcome measures. High levels of feasibility and acceptability were observed for the treatment.

Conclusions

ICBT is a promising and feasible treatment for dental anxiety in children and adolescents. Integrating it into routine pediatric dental care would increase access to an effective psychological treatment. The results of this open trial must be replicated in controlled studies.