|Understanding children's dental anxiety and psychological approaches to its reduction
Dental anxiety is a common problem, which can affect people of all ages, but appears to develop mostly in childhood and adolescence. Childhood dental anxiety is not only distressing for the child and their family but is also associated with poor oral health outcomes and an increased reliance on costly specialist dental services. This article will consider the prevalence, development and implications of children’s dental anxiety. It will also discuss the opportunities for and challenges of psychological approaches such as Cognitive Behavioural Therapy aimed at the reduction of dental anxiety in children.
This article will consider children’s anxiety in the dental setting and will describe the nature of dental anxiety and its implications for the child patient and the dental team. It will also describe a variety of psychological management strategies, based on a theoretical framework of anxiety, and discuss the potential for psychological approaches aimed at the reduction of dental anxiety in children. A wide spectrum of pharmacological regimens can also be used to manage dental anxiety, including various forms of sedation as well as general anaesthesia, however, this article will not evaluate the evidence base of these techniques. It has been proposed that much of the previous literature has focused on the pharmacological approaches to anxiety management . A large proportion of the paediatric dentist’s case-mix may include dentally anxious children, thus it is important that clinicians update their knowledge on the different psychological interventions available now and in the future. It is argued that those dental practitioners who use only narrow set of pharmacological or behavioural strategies may limit their success in treating dentally anxious children and may subsequently need to refer these children to specialist services .
Dental anxiety is a common problem, which can affect people of all ages, but appears to develop mostly in childhood and adolescence . Dental anxiety, dental fear and dental phobia are terms that are often used interchangeably, but actually indicate different types of dental anxiety. Dental fear represents a normal emotional reaction to a specific threatening external dental stimuli, dental anxiety represents a general state in which the individual experiences a level of apprehension and is prepared for something negative to happen and dental phobia is a severe type of dental anxiety which may result in avoidance or endurance of the dental experience with significant discomfort .
The sight, sensation and fear of pain from the needle and dental drill have been frequently shown to be the most fear-evoking stimuli for dentally anxious children . However, whilst children sometimes present with fears of specific treatments, other children report a more general anxiety associated with the dental setting/treatment . It is also to be expected that a proportion of child patients will display anxious behaviours which are not the result of ‘dental anxiety’ (e.g. generalised anxiety). Therefore, assessing the nature of a child’s anxiety is extremely important in determining the most appropriate and effective management strategy. Dental anxiety reaches a clinically significant level when a number of specific diagnoses are met such as avoidance or a significant impact on daily functioning . Studies suggest that just under half of children report low to moderate general dental anxiety and between 10% and 20% report high levels of dental anxiety (e.g. dental phobia) . However, it should be recognised that prevalence rates of childhood dental anxiety and phobia, as reported by different studies, will be influenced by the different measures and cut off points researchers have used to distinguish between those who are and are not anxious .
Development of dental anxiety
There is no single explanation for the development of dental anxiety and a variety of different mechanisms have been applied to understanding the aetiology of dental anxiety. Rachman proposed three different possible mechanisms of fear acquisition which included i) exposure to threatening information ii) vicarious learning (e.g. observing significant others displaying anxious behaviours) and iii) direct experience. Whilst there is limited support for the informational pathway in the acquisition of children’s dental fear research has revealed that child and parental dental anxiety are closely linked, providing some support for the argument that the modelling pathway may be important in the development of children’s dental anxiety . Direct experience, however, has also been found to play a significant role in the development of children’s dental anxiety . Classical conditioning is one of the mechanisms through which fear can develop following previous negative dental encounters. This is the process whereby a once neutral stimuli (e.g. a dental probe) becomes associated with a negative experience (e.g. pain) as a result of these stimuli being paired together in the past (e.g. a painful dental examination) . Indeed children who report previous negative or traumatic dental experiences are more likely to experience higher levels of dental anxiety than those who have had more positive dental experiences .
However, not all children who experience negative dental encounters develop dental anxiety. Davey’s latent inhibition hypothesis proposes that people who have a series of painless appointments, before they experience a traumatic event, are less likely to develop dental anxiety than those people who experience a traumatic dental experience early in their lives and previous research supports this .
Dental anxiety may have major and long-lasting implications for the child and their family. Research has found that children with high levels of dental anxiety have a higher caries experience than children with low levels of dental anxiety . One explanation for the relationship between anxiety and poor oral health outcomes is the vicious cycle which develops whereby the individual’s fear leads them to avoid dental encounters, resulting in neglected dental care and increased unmet need . Fear of going to the dentist can be a significant barrier to the completion of dental treatment in both children and adults . Whilst it could be argued that children themselves may not be in control of whether they attend their dental appointments, there is evidence that parents who consistently fail to take their children to the dentist report that their children’s dental anxiety is one of the influencing factors for their avoidance behaviour . Interestingly, research has found that there may be long-term oral health implications resulting from children’s dental anxiety, as dentally anxious children are more likely to be symptomatic, rather than proactive, users of dental services in adulthood .
Caring for children with dental anxiety can also have a real impact on dental practitioners and dental service provision as it can be time consuming and stressful for the clinician . Previous research has revealed that dental anxiety is the single most important predictor of children’s behaviour in the dental setting and that there are strong associations between dental anxiety and perceived un-cooperative and problem behaviours . There are also financial implications of providing dental treatment to the anxious patient . Dental practices which operate on a fee-per-service basis may not be able to charge for the consultation unless the patient has allowed the dental procedure to be completed. Furthermore, the dentist may be reluctant to undertake dental treatment on the anxious patient for fear of reinforcing the patient’s anxiety . These factors may result in children being referred to secondary dental care services and having to wait longer periods of time for their dental treatment. Indeed, anxious children are one of the key groups that general dental practitioners refer to secondary care services .
Rationale of delivering psychological interventions to dentally anxious children
Dental anxiety and fear-related behaviours are undoubtedly one of the most challenging aspects of paediatric dentistry . Considering the magnitude of evidence associating dental anxiety with poor oral health outcomes in both children and adults, and the significance of children’s early experiences for the development of dental anxiety, it is clearly imperative that the dental team identifies and works with children who exhibit signs of dental anxiety from an early stage.
Whilst there are a range of interventions available to assist the dental team, successful management of a dentally-anxious child usually entails considerable additional time, effort and expertise . Over recent years it has been increasingly recognised that greater effort should be directed towards behaviour management and psychological interventions which can reduce the patient’s anxiety in the long-term without the need for pharmacological support .
Psychological management of children’s dental anxiety
There is emerging evidence that psychological therapies can be used to address the patient’s dental fear and anxiety with reasonably good success, though, the majority of studies have focused on adult patients . Psychological strategies can be used to enhance trust, increase feelings of control and develop coping skills in children with dental anxiety . Clear explanations and procedural information, ‘Tell-show-do’, stop signalling methods/devices, positive feedback during procedures and positive reinforcement are all techniques which can be used to help build up trust and increase patient control and treatment predictability . These strategies are regularly employed by paediatric dentists, with ‘Tell-show-do’ being the most commonly used behavioural strategy . The use of these basic psychological techniques during dental treatment have been found effective in the reduction of children’s dental anxiety .
Whilst these techniques may be adequate for children with mild levels of dental anxiety, children with more pronounced fears may require additional psychological interventions to help them overcome their dental anxiety/fears. It is important that psychological interventions delivered by dentists are evidence based, however, there has been a lack of high quality research (e.g. randomised control trials) investigating the effectiveness of interventions in the field of dental anxiety . There are, however, a number of Empirically Supported Treatments (ESTs) for the management of anxiety problems in children, which are largely based on a Cognitive Behavioural Therapy (CBT) model . CBT is a problem–focused psychological intervention, which seeks to teach patients skills for the self-management of their anxiety. Williams and Garland developed the Five Areas model of assessment and management, which represents a new way of communicating CBT (see Figure 1).
Identify and target life situation (e.g. significant events, parental anxiety) aggression)
Identify and target altered thoughts (e.g. ‘I won’t be able to breathe’ ‘The dentist will be angry with me’)
Identify and target altered emotions (e.g. fear of specific stimuli, generalised dental anxiety, embarrassment)
Identify and target altered physical feelings/ symptoms
(e.g. fainting, physical tension, agitation)
Identify and target altered behaviours
(e.g. avoidance of dental encounter, reliance on pharmacological interventions)
Figure 1. Five Areas approach of dental anxiety (adapted from Williams & Garland’s Five Areas approach of CBT assessment and management )
Five Areas Cognitive Behavioural Therapy approach
The Five Areas approach of CBT is designed to help practitioners assess how the patient’s life situation, thoughts/worries, behaviours, emotions and physical symptoms feed into their experience of anxiety. The purpose of the assessment is to help the practitioner and patient understand how these five areas inter-relate (creating a vicious circle of anxiety) and which area/s should the target for intervention (to ‘break’ the vicious circle of anxiety) . The factors which contribute to an individual’s dental anxiety will determine the most appropriate intervention for reducing the anxiety . For example, a child who is fearful and avoidant of specific dental stimuli may be better suited to a behavioural intervention (e.g. graded exposure) than a child who holds irrational thoughts about the dentist (e.g. ‘the dentist will shout at me’. There is, however, an overlap between the different groups of interventions and a combination of psychological strategies are often employed to reduce children’s anxiety (e.g. graded exposure with cognitive restructuring) . It should also be recognised that an intervention which targets one area (e.g. promotes more adaptive behaviour) is likely to have a positive effect on others areas of the child’s anxiety (e.g. increases positive cognitions). The Five Areas model will be used within this paper to provide a framework for describing a variety of psychological approaches available for the reduction of children’s dental anxiety (Figure 1).
Children’s life situation
There may be many aspects of the child’s life situation and/or their external environment which could be contributing to their dental anxiety. However, parental anxiety has perhaps received the most attention within the literature as an important external factor which may influence the child’s anxiety and behaviour within the dental setting . Providing parents with procedural information about their child’s dental treatments has been found to be an effective intervention in reducing the pre-operative anxiety of parents . The involvement of the child’s parents should also be a key consideration when delivering psychological interventions for children. Parents can learn about helpful and unhelpful approaches for managing their child’s anxious symptoms and behaviours. For example, parents learn not to pressurise children into a feared situation but also not to facilitate avoidance by allowing children to avoid feared stimuli . There is indeed evidence that through watching their child’s progress, parents can learn how to coach children in future anxiety provoking situations .
Children’s altered thoughts
Extreme or negative thinking can also contribute to increased anxiety as unhelpful thinking styles undermine an individual’s perceived ability to cope with a situation . Unhelpful thinking styles may include extreme or catastrophic thinking about the dental encounter/procedure (e.g. ‘I might choke’) or mind-reading and jumping to conclusions (e.g. ‘the dentist won’t understand my fear and will think I’m silly’). Cognitive restructuring refers to a child being taught to recognise the negative thoughts which precipitate their anxiety and replace these with more helpful cognitions . Research has revealed promising results in the use of cognitive strategies to reduce adults dental anxiety , however, there has been a paucity of research investigating the effectiveness of cognitive interventions in reducing children’s dental anxiety.
Children’s altered physical feelings/symptoms
There are a variety of relaxation techniques which can be used with children with dental anxiety such as controlled breathing and progressive muscle relaxation. Relaxation techniques can be used to reduce the physical tension in the anxious patient and teach the individual how to gain control over the physical symptoms caused by their dental anxiety, if this is an area which the individual experiences difficulties in . Pre-appointment preparations such as encouraging children to view audiovisual products and audiovisual distraction are techniques which have also been used to help relax children and reduce their anxiety levels .
The technique of ‘Applied tension’ can be used with patients who may have a tendency to faint during the dental encounter. Within this technique patients are taught how to apply tension to their muscles to increase their blood pressure and reduce the likelihood of fainting . There is evidence that needle phobia may be a separate phenomenon to generalised dental anxiety and it should be recognised that a proportion of children who present with needle phobia may actually be Blood-Injury-Injection phobic. In this group of children it may be the fear of fainting which is precipitating their feelings of anxiety . Exploring the anxious child’s physical symptoms can provide the dental practitioner with an insight into the nature of the child’s fear and the type of intervention which may be most appropriate for their situation.
Children’s altered behaviours
Anxiety can result in people employing behaviours which, whilst may reduce their anxiety in the short term (e.g. avoidance), will further worsen how they feel in the long term . Avoidance behaviours can undermine self-confidence and reinforce negative thoughts and therefore a number of behavioural interventions are designed to challenge these unhelpful behaviours and enable individuals to face their fears. Behavioural interventions such as graded exposure to the feared stimuli and modelling are recognised as treatments with the most substantial evidence base for patients with specific phobias .
Graded exposure and systematic desensitization are techniques which are based on the principle that a patient can overcome their if they are gradually exposed to the feared stimuli in a controlled and systematic way (in vitro or in vivo). Exposure to the feared stimuli or situation is recognised as a central treatment component for specific phobias . It is thought that exposure to a feared stimuli helps individuals overcome their anxiety in three ways: i) encouraging habituation to the feared stimuli; ii) allowing for active elicitation and challenging of catastrophic thoughts associated with the feared stimuli and, iii) preventing behavioural and cognitive avoidance .
Graded exposure involves the patient developing a ‘hierarchy’ of their feared stimuli/situations. Patients are first exposed to their least feared stimuli/situation and are then required to remain in that situation until their level of fear significantly decreases. This process is repeated and only when the patient is no-longer fearful of that stimuli/situation does patient move on to next item in their fear hierarchy . The stages of the fear hierarchy could progress from the child looking around the dental surgery at the lowest level to accepting a dental injection at the highest level . Graded exposure interventions have been found effective in improving the coping strategies and reducing anxiety levels of children suffering from anxiety and specific phobias . To date, there has been a paucity of high-quality research into the effectiveness of graded exposure in children with dental anxiety, however, case studies have provided some evidence that this type of intervention can be highly effective for children with dental anxiety . The technique of systematic desensitization, developed from Wolpe’s original conceptualisation of desensitisation, shares many of the features of graded exposure, however, this techniqe highlights the role of counter-conditioning though the pairing of the graded feared stimuli with a neutral or positive stimulus (e.g. relaxation or emotive imagery) .
Child patients may also learn how to cope with the feared dental situation through the process of modelling. Modelling is based on Bandura’s Social Learning Theory and refers to an indirect learning process whereby patients develop effective coping skills by observing other people (e.g. other children, parents) successfully receiving dental treatment (film, in-vivo) . Modelling can also be used to provide an additional structure to graded exposure experiments in which the therapist may demonstrate each incremental step prior to the client carrying out the interaction with the phobic object or situation . Whilst a series of studies have found modelling to be a useful intervention in improving the behaviour of anxious children in the dental setting , only one in ten paediatric dentists report using live modelling techniques in their practice .
Children’s altered emotions
The Five Areas model encourages practitioners to explore the patient’s emotions and subjective experiences associated with their anxiety . For example, whilst some children may experience a general anxiety towards the dental situation other children may be fearful of specific dental stimuli. Many self-report measures of children’s dental anxiety are available to help identify the nature of the child’s anxiety/fear . It is also possible that children may experience a variety of other emotions associated with their dental anxiety or the dental situation (e.g. feelings of embarrassment or humiliation). Assessment of this area will aid the dental practitioner’s understanding of the emotional impact of the child’s dental anxiety.
Overcoming challenges in the delivery of psychological interventions to reduce dental anxiety
Whilst there is substantial evidence to support the use of CBT in the treatment of anxiety there are a number of barriers which may prevent dentally anxious children receiving evidence-based psychological interventions. Referring dentally anxious children to psychological services can be problematic due to costs and long waiting lists associated with this type of therapy . Dentists themselves, however, may feel reluctant to employ a variety of psychological techniques in their practice. Indeed, only one fifth of General Dental Practitioners report feeling confident providing restorative care to dentally anxious children and just under half of paediatric dentists believe there is not sufficient information on techniques for managing children’s dental anxiety . there is certainly support for argument dentists would benefit from additional training in this area... implications for dental education..etc... Helen.....
It is also important to consider how evidence based interventions are delivered to dentally anxious children and there is a need for these interventions to be adapted and integrated into everyday clinical practice. A promising method of delivering evidence-based psychological interventions, without intensive practitioner input, is by using an assisted self-help approach. Assisted self-help has been found to produce superior results over unsupported (pure) self-help approaches . The greater availability of self-help treatment in primary care and community settings may have the potential to provide cost effective, accessible and appropriate treatment for a range of problems and psychological therapies . Interventions include a range of media-based treatment approaches (e.g. video, workbooks/manuals and audiotapes) and a meta analysis of the effectiveness of these approaches revealed that problems such as fears are particularly amenable to self-help treatments . Indeed, research has revealed that Computerised Cognitive Behavioural Therapy (CCBT) programmes may be as effective as therapist-led cognitive behaviour therapy in the treatment of phobias . However, no age-appropriate self-help programmes currently exist for children with dental anxiety/phobia.
It should be recognised, however, that some patients will require more intensive or flexible approaches than those which can be delivered via a self-help format or by the dental team alone. Indeed, referral to a psychologist is recommended for patients who present with complex problems or have high levels of dental anxiety/extreme phobic reactions which would require the application of complicated cognitive-behavioural strategies .
Childhood dental anxiety is not only distressing for the child and their family but is also associated with poor oral health outcomes and an increased reliance on costly specialist dental services. The reduction of dental anxiety, through the use of effective psychological techniques, is therefore, of utmost importance. Whilst there is a paucity of high-quality research investigating the effectiveness of psychological interventions in managing children’s dental anxiety, there are a number of evidence-supported techniques which could be adapted to meet the needs of dentally anxious children. However, delivery of these interventions needs to be cost-effective and feasible in every day clinical practice. Assisted self-help interventions, based on evidence-supported interventions and sound theoretical frameworks, may offer a promising avenue for the management of childhood dental anxiety.
What this paper adds
This paper provides an insight into the development and implications of dental anxiety in childhood
It describes more recent psychosocial approaches for anxiety management
Why this paper is important to paediatric dentists
It highlights the importance of identifying and managing dental anxiety from an early age
It considers the challenges of incorporating psychological interventions into paediatric dentistry practice
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