Degree of dental anxiety in children with and without toothache: prospective assessment

Effectiveness of Nonpharmacological Behavioural Interventions in Managing Dental Fear and Anxiety among Children: A Systematic Review and Meta-Analysis

BACKGROUND

Non-pharmacological behavioural interventions (NPBIs) have been employed by dentists to alleviate dental fear and anxiety (DFA) among preschool and school children. The aim of this systematic review and meta-analysis was to investigate the effectiveness of different NPBIs in reducing DFA among children aged below 12.

METHOD

A comprehensive search was conducted using four electronic databases to identify randomised controlled trials that assess the effectiveness of NPBIs among preschool and school children. Two reviewers independently screened and selected the relevant studies, evaluated the risk of bias, and extracted relevant data for qualitative and quantitative syntheses.

RESULT

A total of 66 articles were included in the study. Except during more invasive dental procedures, the use of distraction techniques was found to result in significantly lower self-rated anxiety, better cooperation, and lower pulse rate compared to the tell-show-do method. However, inconsistent results were reported regarding the efficacy of virtual reality, modelling, visual pedagogies, tell-show-do and other NPBIs in reducing DFA among children.

CONCLUSIONS

The studies exhibited substantial heterogeneity due to varying age groups, methods of implementing NPBIs, dental treatments performed, and measurement scales employed in the evaluation of DFA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Behaviour of 3-11-year-old children during dental treatment requiring multiple visits: a retrospective study

PURPOSE

To examine children's behaviours during consecutive dental treatments, relative to gender, age, and behaviour guidance techniques.

METHODS

A retrospective study of medical records of children treated by four residents in a Department of Paediatric Dentistry, during 2015-2018. Data included: age, gender, behaviour guidance technique (no medication, inhaled sedation, conscious sedation with hydroxyzine or benzodiazepines) and behaviour according to Frankl scale.

RESULTS

Of 205 children, 134 were 3-6 yo (Group 1) and 71 were 6.1-11 yo (Group 2). Most presented a positive behavioural profile, with significant difference between groups (p = 0.02), no significant difference between genders (p = 0.72). A significant association between behaviour guidance techniques and behavioural profile was found (p = 0.01). Most children with positive behaviour received inhaled sedation (83%), while most children with negative behaviour received conscious sedation using benzodiazepines (8%). Negative behaviour was observed only in the younger children receiving conscious sedation with benzodiazepines (9%) or hydroxyzine (3%).

CONCLUSIONS

Most 3-11 yo patients exhibited positive behaviour during four consecutive dental treatments, with different behaviour guidance techniques. Negative behaviour was more frequent among 3-6 yo children, where sedation was often required to achieve cooperation, and 4.5% could benefit from general anesthesia.

Children with autism spectrum disorder at a dental appointment: problems, behavioral characteristics, recommendations

Relevance. Dental care is one of the principal unmet health needs of children with autism spectrum disorder (ASD). Based on the available publications, the study discusses the dental profile of a child with autism and the social factors affecting the oral health of such children.

Materials and methods. A search was performed of publications for the 15 years in the Medline database using the terms autism”, behavior management/techniques”, child”, dental care for children with other abilities”, dental education”, dental disease”, pediatric dentistry” to find relevant publications.

Results. In the found publications, the authors most frequently mention poor oral hygiene. However, they disagree regarding the caries occurrence rate in children with ASD. Insufficient specialized training of dentists on interaction with special children may be one of the reasons for the limited access to dental care.

Conclusions. Dental treatment of an autistic child requires a thorough knowledge of comorbidity, relevant behavioral management and customization of treatment protocols according to individual needs. The effectiveness, safety and rationale of the known dental treatment strategies for children with ASD require further study and improvement.

Is dental anxiety associated with the behavior of sedated children?

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

Does the pre-emptive administration of paracetamol or ibuprofen reduce trans- and post-operative pain in primary molar extraction? A randomized placebo-controlled clinical trial

BACKGROUND

There is no consensus whether the pre-emptive administration of analgesics reduces trans- and post-operative pain in primary molar extraction.

AIM

Investigate whether the pre-emptive administration of ibuprofen and paracetamol reduces trans- and post-operative pain on primary molars extraction compared to placebo.

DESIGN

A parallel, placebo-controlled, triple-blind, randomized clinical trial was conducted. Forty-eight children who needed primary molar tooth extraction were selected and treated under local anaesthesia and pre-emptive administration of placebo or analgesics. Self-reported pain was evaluated during the anaesthesia, extraction, and 2, 6, and 24 hours of post-operative period, using a visual analogue scale (VAS). Children's baseline anxiety, behaviour during the procedure, parents' anxiety, and post-operative analgesia were also assessed. Data analysis included descriptive statistics and multiple linear regression.

RESULTS

No association was found between the use of pre-emptive analgesic and lower scores of trans- and post-operative pain compared to placebo. Children who presented negative behaviour reported greater pain during anaesthesia (P = .04) regardless of pre-emptive analgesia group. Children from the placebo group were more likely to need post-operative analgesia at 2 hours of follow-up (P = .03).

CONCLUSION

The pre-emptive administration of analgesics did not significantly reduce trans- and post-operative pain in children after primary molars extraction.

The impact of dental anxiety on the oral health of children aged 5 and 8 years: a regression analysis of the Child Dental Health Survey 2013

Introduction Dental anxiety and fear is widely prevalent in the population, including children. This research is a further analysis of the Child Dental Health Survey 2013, to explore the impact of dental anxiety on factors relating to oral health.Aim To explore the relationship between dental anxiety and oral health and the impact dental anxiety has on the quality of family life.Design Regression analysis of data of 4,916 children aged 5 years and 8 years who participated in the Child Dental Health Survey 2013.Setting National Epidemiological Survey in schools in the UK.Materials and methods A series of logistic regression analyses was carried out for markers of oral health and impact of the child's oral health on the family's quality of life. The variables entered as predictors in the models included dental anxiety, socio demographic status and oral health-related behaviours.Results Dental anxiety was associated with poorer oral health on nearly all measures (decay experience p = <0.001, active decay p = <0.001, primary tooth being restored p = 0.010, signs of oral infection p = 0.007) and had a greater impact on their family's quality of life (p = <0.001).Conclusions Dentally anxious children have more dental disease and this has a greater impact on their family's quality of life.

Use of distraction techniques for the management of anxiety and fear in paediatric dental practice: A systematic review of randomized controlled trials

OBJECTIVE

To determine whether distraction techniques (DT) reduce children's/adolescent's anxiety and fear during dental treatment.

METHODS

Randomized controlled trials (RCTs) in which any type of DT were used to manage dental anxiety and dental fear in children/adolescents were included. A systematic search of PubMed, Web of Science, Scopus, Cochrane Library, Lilacs, and Google Scholar was conducted. Two independent reviewers selected studies, extracted data, assessed methodological quality of studies using the Cochrane Collaboration's Risk of Bias tool (CCRBT), and approached certainty of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Data were analysed descriptively.

RESULTS

Twenty studies covering several types of DT (audio, audiovisual, instruments camouflage, biofeedback, dental operating microscope, toys) were included. Qualitative analysis showed with very low certainty of evidence that DT effectively reduced dental anxiety and fear depending on the distraction type, instrument used to measure dental anxiety and dental fear, and dental procedure. CCRBT evaluation identified many methodological issues in included studies.

CONCLUSION

There is a very low certainty of evidence that DT can be effective in managing children's/adolescents' dental fear and anxiety during dental treatment. The heterogeneity of methodologies and findings in the studies, however, suggests more robust, and well-executed RCTs are needed.

The influence of clinical and psychosocial characteristics on children behaviour during sequential dental visits: a longitudinal prospective assessment

PURPOSE

This is the first study to adopt a multilevel approach to assess the impact of the order of dental visits on child's behaviour. The aim was to investigate which factors directly interfere with child's behaviour regardless of the order of sequential dental visits.

METHODS

In this prospective longitudinal study, children aged 7-12 years were invited to participate. Child behaviour was assessed using the Frankl Scale during four sequential dental visits. Chi-square test was used to analyse the effect of dental fear on children's non-cooperative behaviour according to the presence of dental fear. Multilevel mixed logistic regression model was used to assess the association between predictor variables and the outcome (child behaviour) during the sequential dental visits.

RESULTS

Overall, 111 children participated in this study. Maternal dental anxiety, dental pain and complexity of the treatment were associated with the non-cooperative behaviour in children aged 7-12 years. When stratified by dental fear, the complexity of the treatment remained associated with non-cooperative behaviour.

CONCLUSIONS

The results provide evidence that, even with the familiarization of child with the dental environment, maternal dental anxiety, dental pain in the last month, and the complexity of dental treatment negatively affect the children's behaviour aged 7-12 years.

Demystifying behaviour and dental anxiety in schoolchildren during endodontic treatment for primary teeth-controlled clinical trial

BACKGROUND

Behaviour and anxiety of children are predictors of effective dental treatment.

AIM

Compare the behaviour and anxiety during preventive care, endodontic treatment, and dental extraction.

DESIGN

Controlled clinical trial was conducted with 99 children aged 6-9 years. The children were distributed among three groups: G1 (control)-prophylaxis and topical fluoride; G2 (intervention)-endodontic treatment; and G3 (intervention)-tooth extraction. Behaviour was measured using the Frankl scale. Dental anxiety was assessed using the modified Venham Picture Test and measured at three moments: before, during, and after the procedure. Caregivers answered a questionnaire addressing the child's previous dental experience. Clinical examinations were performed by a calibrated examiner (Kappa > 0.70) for the identification of dental caries (d-dmft/D-DMFT). Statistical analysis involved repeated-measures Poisson regression, with level of significance was P < 0.05.

RESULTS

Neither negative behaviour nor anxiety was associated with the type of procedure. Negative behaviour was associated with the need for restraint during a previous dental appointment (P = 0.012). Dental anxiety was associated with age (P = 0.037), previous difficult behaviour (P < 0.001), moment of measurement (P < 0.001), and dental caries on permanent teeth (P = 0.001).

CONCLUSIONS

Negative behaviour and dental anxiety in children were not associated with the type of treatment performed.

Effectiveness of topical haemocoagulase as a haemostatic agent in children undergoing extraction of primary teeth: a split-mouth, randomised, double-blind, clinical trial

AIM

To assess the effectiveness of topically-administered haemocoagulase (batroxobin) (HC) following dental extractions in children.

DESIGN

Split-mouth design, where either HC (test) or Normal Saline (control) (NS) was administered to children (5-9 years) requiring bilateral extractions of primary molars. Participants were randomised to (i) extraction sequence; (ii) test-solution administered thereafter.

OUTCOME MEASURE

time taken (in seconds) for complete cessation of bleeding.

RESULTS

Thirty participants completed the trial receiving HS (n = 30) and NS (n = 30). No adverse events were reported. Time to bleeding cessation was lower in HS group (82.5 ± 13.99 s) than NS group (240.5 ± 54.34 s). Difference between groups (paired t test) was statistically very highly significant (P = 0.000).

CONCLUSION

Topical HC produced significant reductions in time for haemostasis and was clinically effective in controlling haemorrhage from extraction wounds in children. HC may be favourably utilised by paediatric dentists, especially with pre-cooperative or special-healthcare-needs patients, improving patient care.

The reassuring role of music associated with the personality traits of children during dental care: a randomized clinical trial

AIM

The objective of this study was to analyze the reassuring role of music associated with the personality traits of children during dental care.

METHOD

The study involved a randomized crossover clinical trial with 34 children, aged from 4 to 6 years, who exhibited two carious lesions on the occlusal surfaces of the molars. The children were divided into two groups: (G1) first tooth restoration intervention session with music, second session without music; and (G2) first tooth restoration intervention session without music, second session with music. The first consultation was to perform a clinical examination, and the second and third to perform modified Atraumatic Restorative Treatment (mART). Symphony No. 40 by Mozart was played via headphones. Pulse rate (PR) was measured using a pulse oximeter. The Brazilian version of the Eysenck Personality Questionnaire-Junior (EPQ-J) was used to measure the children's personality. For statistical analysis, descriptive, Chi-square, and Wilcoxon tests were carried out.

RESULTS

The G1 group exhibited a lower PR at the time of the intervention during the second consultation compared to the third consultation (p = 0.012). The G2 group exhibited a lower PR at the time of the intervention during the third consultation compared to the first consultation (p = 0.002). The majority of the children with a low level of extraversion presented with higher PR (p = 0.005).

CONCLUSION

Music could reduce the PR among children during dental intervention. Children with low extraversion showed a tendency towards a higher PR without music during dental care.

Behavior of Children toward Various Dental Procedures

Introduction

Dental treatment is known to trigger anxiety and fear even in fully grown adults, especially if administration of local anesthesia with a syringe is indicated. This study is aimed to evaluate whether procedures like an extraction and pulpectomy could trigger fear and anxiety in a pediatric patient and also the response of pediatric patients to other treatment modalities. Their perception toward receiving dental treatment as a whole is also evaluated. The effect of conditioning of the environment and the dentist (extractions done in second or third appointments) and its effect in decreasing the anxiety is also evaluated. The aim of the study is to evaluate the behavior of pediatric patients aged 7–17 years in response to various treatment procedures at Saveetha Dental College.

Materials and methods

The behavior of 50 children reporting to Saveetha Dental College, categorized according to the Frankl's behavior rating scale, was recorded before, during, and posttreatment.

Results

Children undergoing extractions and pulpectomies showed the most uncooperative behavior. Sixty percent of patients undergoing extraction and 45% of patients undergoing the pulp therapy showed negative behavior (rating 2) during treatment.

Conclusion

Invasive procedures like extractions and pulpectomies were procedures that brought out negative behavior in pediatric patients, especially during treatment.

How to cite this article

Sivakumar P, Gurunathan D. Behavior of Children toward Various Dental Procedures. Int J Clin Pediatr Dent 2019;12(5):379–384.

The Influence of Stress and Anxiety on the Expectation, Perception and Memory of Dental Pain in Schoolchildren

The aim of this study was to investigate the association of stress and anxiety with the expectation, perception and memory of dental pain among schoolchildren. A follow-up study involving 46 children aged 9 to 12 years was conducted in a public school in the city of Petropolis (RJ), Brazil. Demographic characteristics, stress (children's stress scale), and state and trait anxiety (state⁻trait anxiety inventory) were recorded before a dental procedure to restore the occlusal surface of a permanent first molar under local anaesthetic. Dental pain was assessed using the faces pain scale before (dental pain expectation), immediately after (dental pain perception) and six weeks after (memory of dental pain) the dental procedure. Dental pain expectation scores were significantly higher than dental pain perception, independent of the levels of stress, state anxiety and trait anxiety. Children with high scores of stress (OR 1.05 95%CI 1.02⁻1.09), state anxiety (OR 1.15 95%CI 1.05⁻1.27) and trait anxiety (OR 1.18 95%CI 1.07⁻1.30) were more likely to report greater scores of dental pain expectation. Children anticipated more dental pain than what was actually perceived after the dental restoration. Children with greater levels of stress and anxiety have a distorted evaluation of expected dental pain before the dental procedure.

Barriers and Drawbacks of the Assessment of Dental Fear, Dental Anxiety and Dental Phobia in Children: A Critical Literature Review

OBJECTIVE

Dental anxiety, fear and phobia have different etiology, response patterns, time courses, and intensities that justify a clear distinction between these constructs. Differentiation of dental anxiety, fear or phobia in practice is a critical prerequisite for developing and implementing effective treatment for children. The aim of this study was to investigate whether current researches in the pediatric dentistry appropriately discriminate the central construct of dental anxiety, fear and phobia. We also highlighted the specific methodological issues in the assessment of these issues in pediatric dentistry.

STUDY DESIGN

A systematic search was conducted in Pubmed/medline and Scopus for articles which assessed dental anxiety, fear or phobia in children.

RESULTS

104 research papers were included in the review that had made a distinction between dental anxiety, fear and phobia and had not used them interchangeably. Only five studies used different clinical measures or cut-offs to discriminate between dental anxiety, fear and phobia.

CONCLUSION

The dental literature appears unable to capture and also measure the multi-sided construct of dental anxiety, fear and phobia and, therefore, there was a tendency to use them interchangeably.

Professional dental prophylaxis increases salivary cortisol in children with dental behavioural management problems: a longitudinal study

Background

Dental procedures may cause stress and increase the salivary cortisol levels. It is important to known if apparently simple procedures such as professional dental prophylaxis at low speed (DP) are stressful for children with dental behaviour management problems (DBMP) to help with behaviour guidance strategies. This longitudinal study aimed to evaluate if DP changes a physiological marker of stress (salivary cortisol) in children with DBMP who were referred to dental treatment under sedation.

Methods

One paediatric dentist carried out a DP with rubber cup and pumice followed by dental examination in 39 children aged 2–5 years, prior to the dental sedation appointment. Children’s saliva was collected at three different moments: upon waking (UW), on arrival at the dental office reception area (RA) and 25 min after the dental prophylaxis (DP). The saliva samples were analysed using an enzyme immunoassay kit. The Wilcoxon test was used in paired comparison (P < 0.05).

Results

Salivary cortisol levels decreased from UW (0.34; 0.15–0.54) to RA (0.14; 0.08–0.56) (P = 0.019) and increased from RA to DP (0.25; 0.06–1.48) (P = 0.008). Higher salivary cortisol levels were observed at DP when compared to RA in children who did not have previous dental treatment (P = 0.007), had toothache (P = 0.006), presented some protest behaviour during DP (P = 0.008), or needed protective stabilisation by parents for the dental examination (P = 0.005).

Conclusions

Paediatric dentists should be aware that even simple procedures such as professional dental prophylaxis are related to stress in young children.