Development and Testing of a Cognitive Behavioral Therapy Resource for Children's Dental Anxiety

Web-Based Interventions Reduced Dental Anxiety among Adults in Lithuania and Norway: A Pilot Study

Dental anxiety (DA) is a prevalent public health issue. However, there is a lack of self-administered DA interventions. The aim of this study was to evaluate the short-term effects of web-based interventions aiming to reduce DA in adults in two European countries. A pretest posttest design was used. Tailor-made websites were developed in Lithuania and Norway. Volunteers who self-reported DA were invited to participate. DA levels measured by the Modified Dental Anxiety Scale (MDAS) were assessed at baseline and after two weeks via online questionnaires. The interventions were completed by 34 participants in Lithuania and 35 participants in Norway. In Lithuania, the median posttest MDAS score (9.5, IQR 5.25) decreased compared to the median pretest MDAS score (14.5, IQR 8; Z value = -4.246, p < 0.001). The same was found in Norway-the median posttest MDAS score (12, IQR 9) was lower compared to the median pretest MDAS score (15, IQR 7; Z value = -3.818, p < 0.001). The present study demonstrated that two tailor-made web-based interventions had the potential to reduce dental anxiety levels when assessed in the short term in Lithuania and Norway. Studies with more controlled designs assessing long-term outcomes are needed to validate the results of this pilot study also in other cultures.

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

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSION

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

The 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.

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

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

Behavioral Sciences in the Promotion of Oral Health

The importance and value of behavioral sciences in dentistry have long been recognized, and their contribution to dental education, research, clinical practice, and oral health policy has been significant over the past half century. Over time behavioral sciences have expanded our understanding of oral health beyond "disease" to a broader biopsychosocial concept of oral health. This in turn has led dentistry away from a focus of "treatment" to oral health "care," notably in the new millennium. Key oral health behaviors have been identified for more than half a century: the importance of diet, oral hygiene, dental services, and other factors. Various behavioral models and theories have been proposed, particularly since the 1970s, providing useful frameworks with sound psychological basis to help understand the paths of oral health behaviors. These models draw on theories of self-efficacy, motivation, counseling, and "behavior change." Since the 1980s, there has been a greater understanding that these behaviors often share a common pathway with the etiology of other diseases (common risk factors). Furthermore, the relationship between individual factors and the broader environmental factors has been increasingly emphasized since the 1990s, leading to a united call for action in addressing oral health inequalities. Within the past decade, there are useful examples of models, frameworks, and techniques of behavior change with respect to oral health, involving planning, prompting, encouraging, goal setting, and/or motivating. In particular, there is a growing interest and use of motivational interviewing. Likewise, behavioral therapies, such as cognitive behavioral therapy, are increasingly being employed in dental practice in the management of dental anxiety, pain, and psychosomatic dental and oral problems, with promising results. Recommendations are outlined for future directions for behavioral sciences in the promotion of oral health.

COVID-19: implications for paediatric dental general anaesthetic services

Will the coronavirus pandemic bring about change in how we manage children with caries?

'I Would Rather Be Having My Leg Cut off Than a Little Needle': A Supplementary Qualitative Analysis of Dentally Anxious Children's Experiences of Needle Fear

Fear of needles is common in childhood, with up to 50% being affected to some degree. In individuals who are dentally anxious, the prevalence may be as high as 91%. Fear of needles, and therefore intra-oral injections can have negative impacts on children's quality of life and healthcare experiences, including a requirement for pharmacological methods to facilitate dental treatment. The aim of this study is to identify whether dentally anxious children report fear of injections and explore how these children experience a fear of needles in a dental setting. A supplementary analysis of interviews collected as part of two previous studies relating to children with dental anxiety. Five main themes were identified: feelings about needles; the nature of needle fear; the context of the fear, its consequences and how children tried to control the process. Children showed a desire to have control of their healthcare interventions, and wanted to trust the healthcare professionals giving the injections. There is evidence that children with dental anxiety also experience fear of needles, including intra-oral injections. Further primary qualitative research is needed to explore this topic in more depth and to design appropriate child centred interventions to reduce needle fear.

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.

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

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

Outcome of Chair-Side Dental Fear Treatment: Long-Term Follow-Up in Public Health Setting

Aim

Purpose of this practice and data-based study was to evaluate the outcome of dental fear treatment of patients referred to the Clinic for Fearful Dental Patients (CFDP) in the primary oral health care, City of Oulu, Finland, during period 2000–2005.

Methods

A psychological approach including behavioral interventions and cognitive behavioral therapy (BT/CBT) was used for all participants combined with conscious sedation or dental general anesthesia (DGA), if needed. The outcome was considered successful if later dental visits were carried out without any notifications in the patient records of behavioral problems or sedation. Data collection was made in 2006; the average length of the observation period from the last visit in the CFPD to data collection was 2 y 3 m (SD 1 y 5 m). All information was available for 163 patients (mean age 8.9 y at referral). Study population was dominated by males (58.0%). Cause for referrals was mostly dental fear (81.0%) or lack of cooperation.

Results

The success rate was 69.6% among females and 68.1% among males. Success seemed to be (p=0.053) higher for those treated in ≤12 years compared with the older ones. The participants, without need for dental general anesthesia (DGA) in the CFDP, had significantly a higher success rate (81.4%) compared with those who did (54.8%, p < 0.001). Use of conscious oral sedation (p=0.300) or N₂O (p=0.585) was not associated with the future success.

Conclusions

A chair-side approach seems successful in a primary health care setting for treating dental fear, especially in early childhood. Use of sedation seems not to improve the success rate.

Management of carious primary molars within the community dental setting in Wales: a retrospective observational study

Background Tertiary prevention is still an integral part of a child's healthcare. In community dental service (CDS), we aim to try to restore carious primary teeth in young children as a means of caries control.Aim To assess the survival rates of individual carious primary molars within CDS, based on the type of dental interventions.Design Retrospective observational study.Methods Fifty patients' notes were reviewed, and patients were selected using a defined protocol. The Kaplan-Meier method was used to estimate the survival curves.Results Out of 251 teeth, the estimated survival rates of teeth restored with stainless steel crowns (SSC) was the highest at 46.7 months, GIC-restored teeth at 45.8 months and unrestored teeth at 18.2 months. There was no correlation seen between the survival rates and the number of further interventions required. The difference between the survival rates of teeth restored with GIC, SSC and unrestored was statistically significant (p <0.05). There was minimal use of SSCs within this sample.Conclusion Our present findings indicate that restored teeth have higher survival rates than unrestored teeth. However, it must be emphasised that restorative treatment may not always be feasible and other factors should be considered in the treatment planning.

Evaluation of Self-Help Cognitive Behavioural Therapy for Children's Dental Anxiety in General Dental Practice

Dental anxiety is very common; however, there is a lack of studies focusing on reducing children’s dental anxiety. One such initiative, the guided self-help cognitive behavioural therapy (CBT) resources ‘Your teeth, you are in control’, reduces dental anxiety in children attending paediatric dentistry clinics. This service evaluation aims to investigate whether such CBT resources reduce children’s dental anxiety when implemented in general dental practice. A convenience sample of children was given the resources by their dental practitioner. There was no control group. Children completed the Children’s Experiences of Dental Anxiety Measure (CEDAM) prior to using the resources and on completion of a course of dental treatment. Overall, 84 children were involved, with a mean age of 10.9 years; 48 were female and 59 were living in the most deprived area of England. At baseline the mean CEDAM score was 20.3, and on receiving the resource and completing treatment the mean CEDAM score was 16.4, showing a significant reduction in dental anxiety (t = 14.6, (df = 83), p < 0.001, 95% CI: 3.4–4.4). The items that improved the most were worry over having dental treatment and dental treatment being painful. The service evaluation indicates a reduction in child dental anxiety following the use of CBT resources in general practice. Further evaluation, preferably a randomised controlled trial, is needed.

Prevalence of dental anxiety and associations with oral health, psychological distress, avoidance and anticipated pain in adolescence: a cross-sectional study based on the Tromsø study, Fit Futures

OBJECTIVE

To describe the prevalence of dental anxiety (DA) among adolescents in Tromsø and Balsfjord region in northern Norway and present a multivariate logistic regression model to predict high dental anxiety scores (DASs) among these adolescents.

MATERIALS AND METHODS

We used self-report questionnaires and clinical dental examination data from adolescents registered in upper secondary school (15-18 years of age) in this region (n = 986). Logistic regression was used to estimate odds ratios and their 95% confidence intervals (CI) when using Corah's DAS as a dichotomous dependent variable.

RESULTS

Twelve percent of the respondents reported a DAS score ≥13, indicating high DA. The strongest predictors for reporting high DA were anticipated pain at the dentist, 'external control belief', avoidance, low social motivation on oral health behaviour and sex. In this population, dental caries (DMFS), symptoms of psychological distress (HSCL-10) and self-motivation concerning oral health behaviour did not differ significantly between those reporting high DA (DAS ≥13) and those that reported low DA (DAS ≤12).

CONCLUSIONS

Severe DA in adolescence is a dental public health challenge and this study shows that DA is a hindrance to seeking dental treatment irrespective of dental status. Dental anxiety should have a higher focus on preventive oral health strategies and have a higher priority in public dentistry to avoid this problem to escalate into adulthood.

The effectiveness of Cognitive Behavioural Therapy in the reduction of dental anxiety in children

Data sourcesCochrane Library, Embase, PubMed, Scopus, Web of Science, LILACS/BBO, PsycINFO, ClinicalTrials, ISRCTN registry, UK National Institute for Health and Care Excellence, International Clinical Trials Registry Platform, ProQuest and OpenGrey.Study selectionTwo independent and calibrated reviewers selected randomised controlled trials investigating cognitive behavioural therapy use in dentally anxious children.Data extraction and synthesisRisk of bias was assessed by two independent reviewers according to the Cochrane Collaboration tool. Clinical and methodological heterogeneity were assessed to determine whether a meta-analysis could be performed but the data were not similar enough and therefore a narrative synthesis is provided.ResultsSix studies were included, all written in English between 1980 and 2017. Two were completed in the United States, one in Jamaica, one in Iran, one in Sweden and one in Norway and included 269 patients in total ranging from 41 months to 18 years. Two studies had high risk of bias. In five studies, CBT patients showed significantly reduced levels of anxiety. In three studies improvement was observed in cooperation/behaviour. In two studies, avoidance behaviours improved.ConclusionsCBT has been shown in published literature to have a positive effect on childrens anxiety and co-operation; however the quality of evidence for this is low. There is no current consensus on which outcome measure/s should be used, which prevents meta-analysis of results. Further randomised controlled studies are required, ideally using the same outcome measures, to develop evidence based guidance on the use of CBT in dentally anxious children.

Change in Oral Health-Related Quality of Life Following Minimally Invasive Aesthetic Treatment for Children with Molar Incisor Hypomineralisation: A Prospective Study

Molar incisor hypomineralisation (MIH) is a common enamel condition, presenting with incisor opacities, which may be of psychosocial concern to children. This clinical study sought to determine whether minimally invasive treatment, aiming to improve incisor aesthetics, would also improve children's oral health-related quality of life (OHRQoL). 111 MIH patients, aged 7⁻16 years, referred to a UK Dental Hospital, were invited to complete the Child Oral Health Impact Profile (C-OHIP-SF19) prior to any intervention (T₀) and again at one-month following the intervention (T₁) for MIH. Treatment regimens included one or more of the following: Microabrasion; resin infiltration; tooth whitening; resin composite restoration. Data were obtained for 93 children with a mean age of 11 years. Mean total C-OHIP-SF19 score at T₀ was 47.00 (SD = 9.29; range = 0⁻76) and this increased significantly at T₁ to 58.24 (SD = 9.42; range = 0⁻76; p < 0.001, paired t-test), indicating a marked improvement in self-reported OHRQoL. There were no statistically significant differences according to gender. This is the first study to show that simple, minimally invasive dental treatment, to reduce the visibility of enamel opacities, in MIH, can have a positive impact on children's wellbeing.

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.